From d0547cab8d0ed7557acc3dd899ca153e81d965fb Mon Sep 17 00:00:00 2001 From: Cursor Agent Date: Wed, 8 Jul 2026 18:22:48 +0000 Subject: [PATCH] fix(answer): dedupe and compact Also in your library cross-mode links Wire CrossModeLinksSection inline inside StagedAnswerResultSurface so the library strip stays latched below answer content instead of rendering twice. Compact card layout: tighter padding, single-line subtitle, one search action. Add cross-mode link infrastructure, medication catalog API (snapshot-backed), and Playwright coverage asserting exactly one cross-mode strip on answer. Co-authored-by: BigSimmo --- data/medications-snapshot.json | 97839 ++++++++++++++++ src/app/api/medications/[slug]/route.ts | 49 + src/app/api/medications/route.ts | 90 + src/components/ClinicalDashboard.tsx | 13 +- .../answer-result-surface.tsx | 10 + .../clinical-dashboard/cross-mode-links.tsx | 182 + .../clinical-dashboard/favourites-hub.tsx | 1 + .../clinical-dashboard/source-actions.tsx | 14 + .../use-medication-catalog.ts | 145 + src/lib/catalog-search.ts | 173 + src/lib/cross-mode-differentials.ts | 40 + src/lib/cross-mode-links.ts | 273 + src/lib/keyword-query.ts | 104 + src/lib/medication-badges.ts | 356 + src/lib/medication-fixtures.ts | 5 + src/lib/medication-records.ts | 50 + src/lib/medication-seed.ts | 3 + src/lib/medication-snapshot.ts | 17 + src/lib/medications.ts | 271 + src/lib/semantic-tone.ts | 98 + tests/catalog-search.test.ts | 122 + tests/cross-mode-links.test.ts | 141 + tests/medication-badges.test.ts | 145 + tests/ui-smoke.spec.ts | 79 + 24 files changed, 100219 insertions(+), 1 deletion(-) create mode 100644 data/medications-snapshot.json create mode 100644 src/app/api/medications/[slug]/route.ts create mode 100644 src/app/api/medications/route.ts create mode 100644 src/components/clinical-dashboard/cross-mode-links.tsx create mode 100644 src/components/clinical-dashboard/use-medication-catalog.ts create mode 100644 src/lib/catalog-search.ts create mode 100644 src/lib/cross-mode-differentials.ts create mode 100644 src/lib/cross-mode-links.ts create mode 100644 src/lib/keyword-query.ts create mode 100644 src/lib/medication-badges.ts create mode 100644 src/lib/medication-fixtures.ts create mode 100644 src/lib/medication-records.ts create mode 100644 src/lib/medication-seed.ts create mode 100644 src/lib/medication-snapshot.ts create mode 100644 src/lib/medications.ts create mode 100644 src/lib/semantic-tone.ts create mode 100644 tests/catalog-search.test.ts create mode 100644 tests/cross-mode-links.test.ts create mode 100644 tests/medication-badges.test.ts diff --git a/data/medications-snapshot.json b/data/medications-snapshot.json new file mode 100644 index 000000000..e32851a61 --- /dev/null +++ b/data/medications-snapshot.json @@ -0,0 +1,97839 @@ +[ + { + "slug": "acamprosate", + "name": "Acamprosate", + "class": "Addiction", + "subclass": "GABA / Glutamate Modulator", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "AUD", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1998 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "13-28.4 h", + "cls": "", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Efficacy", + "value": "MODERATE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Anti-craving agent indicated to maintain abstinence in alcohol-dependent patients. Use with counselling; initiate after the withdrawal period and continue if relapse occurs.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1998 mg/day** (Requires taking 2 large tablets, 3 times a day).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Renal function is the key safety limiter: Australian PI contraindicates use in renal insufficiency (serum creatinine >120 micromol/L). Severe hepatic failure (Child-Pugh C), pregnancy, and breastfeeding are contraindications; avoid use in children/adolescents <18 and adults >65 because safety/efficacy are not established.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Acamprosate is an anti-craving agent for maintaining alcohol abstinence after detoxification, but requires good renal function and is only effective when combined with psychosocial support.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Diarrhea, nausea, flatulence (very common, dose-dependent).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Pruritus, maculopapular rash.", + "tags": [] + }, + { + "key": "Neurological", + "val": "LOW — Mood swings, depression (ensure underlying psychiatric conditions are monitored).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Alcohol Abstinence Maintenance (>60 kg)", + "val": "**PO** 2 tablets (666 mg) **TDS** with meals (Total 1998 mg/day).", + "tags": [] + }, + { + "key": "Alcohol Abstinence (<60 kg)", + "val": "**PO** 2 tabs morning, 1 tab midday, 1 tab night.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CONTRAINDICATED — Australian PI contraindicates acamprosate in renal insufficiency (serum creatinine >120 micromol/L). Do not rely on the current eGFR thresholds unless they are separately source-reviewed.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Campral", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Enteric-coated tablets (333 mg). Do not crush.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (STREAMLINED PBS), item 8357W; acamprosate calcium 333 mg enteric tablet, 180.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance of abstinence in alcohol-dependent patients.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line relapse-prevention option for patients seeking abstinence, alongside naltrexone. Particularly useful when opioid therapy makes naltrexone unsuitable, but avoid renal insufficiency and severe hepatic failure (Child-Pugh C).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Contraindicated with hypersensitivity to acamprosate, renal insufficiency (serum creatinine >120 micromol/L), severe hepatic failure (Child-Pugh C), pregnancy, or breastfeeding.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "scr": { + "gt": 120 + } + }, + "note": "Source-backed from Campral Australian PI; matches serum creatinine >120 micromol/L." + } + }, + { + "key": "Hepatic", + "val": "CONTRAINDICATED — Severe hepatic failure (Child-Pugh C). Although hepatic dysfunction does not alter pharmacokinetics, the PI states safety and efficacy are not established in severe hepatic failure.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Source-backed from Campral Australian PI; applies to severe hepatic failure (Child-Pugh C)." + } + }, + { + "key": "Pregnancy", + "val": "CONTRAINDICATED — Pregnancy category B2; do not administer during pregnancy. Breastfeeding is also contraindicated.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "contraindication", + "severity": "danger", + "note": "Source-backed from Campral Australian PI; pregnancy and breastfeeding are contraindicated." + } + }, + { + "key": "Elderly", + "val": "AVOID — Safety and efficacy are not established in patients older than 65 years; Australian PI states acamprosate should not be administered to elderly patients.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "caution", + "severity": "danger", + "match": { + "age": { + "gt": 65 + } + }, + "note": "Source-backed from CAMPRAL Australian PI; applies to patients older than 65 years." + } + }, + { + "key": "Paediatric", + "val": "AVOID — Safety and efficacy are not established in patients younger than 18 years; Australian PI states acamprosate should not be administered to children.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "caution", + "severity": "danger", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Source-backed from CAMPRAL Australian PI; applies to patients younger than 18 years." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — No pharmacokinetic interaction shown with diazepam, disulfiram, or imipramine. Naltrexone increases acamprosate exposure, but the PI states no dose adjustment is necessary. Monitor carefully with psychotropics not studied.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check renal function before prescribing; renal insufficiency with serum creatinine >120 micromol/L is contraindicated. If liver disease is suspected, assess hepatic status/LFTs because severe hepatic failure (Child-Pugh C) is contraindicated.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "monitor", + "severity": "caution", + "match": { + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "Assess hepatic status/LFTs where liver disease is suspected; severe hepatic failure (Child-Pugh C) remains contraindicated." + } + }, + { + "key": "Bedside", + "val": "MONITOR — Monitor depression and suicidality symptoms in alcohol-dependent patients. Also assess adherence, because three-times-daily dosing and tablet burden can limit effectiveness.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "No Disulfiram Effect", + "val": "Ensure the patient knows that if they relapse and drink alcohol, Acamprosate will NOT make them violently ill. They can safely continue taking it while re-engaging with detox protocols.", + "tags": [] + }, + { + "key": "The Post-Detox Start", + "val": "Start as soon as possible after the withdrawal period. Continue treatment if relapse occurs; the recommended treatment period is 1 year.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Mechanism is not fully established. The PI describes acamprosate as structurally similar to amino acid neuromediators and notes animal evidence of reduced glutamatergic hyperactivity in alcohol withdrawal, rather than a confirmed direct GABA/NMDA effect.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks to achieve steady state and clinical efficacy.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Apparent elimination half-life after oral 666 mg dosing ranges from 13 to 28.4 hours. Hepatic dysfunction does not alter pharmacokinetics; acamprosate is not metabolised and is eliminated in urine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check — TGA ARTG 286653, CAMPRAL Australian PI, PBS item 8357W, Australian Prescriber alcohol-dependence review, and DACAS acamprosate factsheet checked 2026-06-30 for this entry." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "GABA / Glutamate Modulator — Anti-craving agent for Alcohol Use Disorder (AUD)." + }, + { + "label": "Route / Formulation", + "value": "Enteric-coated tablets (333 mg). Do not crush. (Campral)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 2 tablets (666 mg) **TDS** with meals (Total 1998 mg/day). Max **1998 mg/day** (Requires taking 2 large tablets, 3 times a day)." + }, + { + "label": "Key Indication Doses", + "value": "Alcohol Abstinence Maintenance (>60 kg): **PO** 2 tablets (666 mg) **TDS** with meals (Total 1998 mg/day). Alcohol Abstinence (<60 kg): **PO** 2 tabs morning, 1 tab midday, 1 tab night. Renal Impairment: contraindicated if serum creatinine >120 micromol/L; do not rely on eGFR dose thresholds unless separately source-reviewed." + }, + { + "label": "Best Uses", + "value": "Acamprosate is an anti-craving agent for maintaining alcohol abstinence after detoxification, but requires good renal function and is only effective when combined with psychosocial support." + }, + { + "label": "Avoid / Cautions", + "value": "Contraindicated in renal insufficiency (serum creatinine >120 micromol/L), severe hepatic failure (Child-Pugh C), pregnancy, breastfeeding, and hypersensitivity. Do not use in children/adolescents <18 or adults >65 because safety/efficacy are not established. Pregnancy category B2." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Diarrhea, nausea, flatulence (very common, dose-dependent). Dermatological: Pruritus, maculopapular rash. Neurological: Mood swings, depression (ensure underlying psychiatric conditions are monitored)." + }, + { + "label": "Key Interactions", + "value": "No pharmacokinetic interaction shown with diazepam, disulfiram, or imipramine. Naltrexone increases acamprosate exposure, but no dose adjustment is necessary. Monitor carefully with psychotropics not studied." + }, + { + "label": "Monitoring", + "value": "Check renal function before prescribing. Assess hepatic status/LFTs where liver disease is suspected. Monitor depression/suicidality symptoms and adherence during treatment." + }, + { + "label": "Clinical Pearl", + "value": "Ensure the patient knows that if they relapse and drink alcohol, Acamprosate will NOT make them violently ill. They can safely continue taking it while re-engaging with detox protocols." + } + ] + }, + { + "slug": "buprenorphine-sl-depot", + "name": "Buprenorphine (SL/depot)", + "class": "SUD", + "subclass": "Partial Opioid Agonist", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "OUD / S8", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "Buvidal 160 mg/month; Sublocade 300 mg/month", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "Days to Weeks", + "cls": "good", + "flag": "" + }, + { + "label": "Resp. Depression", + "value": "CEILING", + "cls": "good", + "flag": "" + }, + { + "label": "Precip. W/D", + "value": "CRITICAL RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Buprenorphine partial mu-opioid agonist for opioid-dependence treatment, available as sublingual products and long-acting SC depot injections. Depot products reduce daily dosing burden but require correct induction and follow-up.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Depot maximums differ by product: Buvidal monthly dosing can be 64-160 mg; Sublocade monthly dosing is usually 300 mg for two months then 100 mg, with 300 mg monthly maintenance in selected tolerated inadequate-response cases.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Depot buprenorphine should follow appropriate buprenorphine induction/tolerance confirmation. Giving buprenorphine too soon after full agonists can precipitate withdrawal; depot administration makes rapid dose reversal difficult.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Buprenorphine (SL/depot) is a partial opioid agonist for opioid dependence and pain, but initiation requires mild withdrawal state and the ceiling effect limits analgesic utility in severe acute pain.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Precipitated withdrawal (if given too early). HIGH — Headache, insomnia, sweating.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Constipation, nausea.", + "tags": [] + }, + { + "key": "Tissue", + "val": "HIGH — Sublocade forms a solid lump under the skin that can be painful. Must be injected into abdominal fat.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Opioid Use Disorder (Sublingual Induction)", + "val": "**SL** 2-4 mg STAT only when the patient is in OBJECTIVE moderate withdrawal (COWS > 12). Titrate to 16-24 mg/day.", + "tags": [] + }, + { + "key": "Subcutaneous Depot (Buvidal)", + "val": "**SC by healthcare professional** weekly 8-32 mg or monthly 64-160 mg, with dose adjusted to clinical response according to product guidance.", + "tags": [] + }, + { + "key": "Subcutaneous Depot (Sublocade)", + "val": "**SC abdominal injection by healthcare professional**. Verify transmucosal buprenorphine tolerance before first injection. Usual regimen is 300 mg monthly for the first two months, then 100 mg monthly; 300 mg monthly maintenance may be used if tolerated and response is inadequate.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Subutex (SL), Buvidal (SC), Sublocade (SC)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Sublingual tablets (0.4, 2, 8 mg). Must dissolve completely.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Long-acting SC depot injection only; administer by a healthcare professional. Sublocade is injected into abdominal subcutaneous tissue and must not be injected IV, IM, or intradermally.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "S8. PBS search shows buprenorphine modified-release injection strengths under S100 HSD Community Access; confirm product-specific item/restriction and jurisdictional OAT requirements before prescribing.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment for Opioid Use Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The gold standard. The monthly SC depots have revolutionized OUD by removing the need for daily pharmacy visits, completely halting diversion/street sale.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe respiratory insufficiency. Patient not currently in withdrawal during induction.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION - Pregnancy category C. Use during pregnancy or lactation only after specialist benefit-risk review; do not display pregnancy as SAFE or as an absolute contraindication from these sources.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "Depot buprenorphine PI sources require benefit-risk review in pregnancy/lactation." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL - CNS depressants and other opioids increase sedation and respiratory-depression risk. Buprenorphine may complicate acute pain management; use specialist multimodal analgesia rather than assuming standard opioids simply fail.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Must use the Clinical Opiate Withdrawal Scale (COWS) before the first SL dose. Do not dose unless COWS > 12.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY - Check baseline liver function and document viral hepatitis status where relevant before depot therapy; monitor hepatic events during treatment, especially with hepatic impairment or hepatotoxic co-medications.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "monitor", + "severity": "caution", + "match": { + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "Depot PI recommends baseline liver function assessment and monitoring hepatic events." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Ceiling Effect", + "val": "Buprenorphine has a ceiling effect for respiratory depression compared with full agonists, but serious respiratory depression can still occur, especially in non-tolerant patients or with CNS depressants.", + "tags": [] + }, + { + "key": "The Depot Revolution", + "val": "Depot buprenorphine can reduce daily dosing burden and diversion opportunity, but it is not instantly reversible; confirm stability/tolerance and plan follow-up before injection.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to the mu-opioid receptor with extreme tightness (higher affinity than Naloxone or Heroin), but only 'partially' turns it on. This provides enough stimulation to stop cravings, but caps the respiratory depression.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SL** 30-60 mins. **SC** 24 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Sublingual buprenorphine has a long terminal half-life; depot products release buprenorphine over weeks to months. Do not use a single half-life number to guide depot switching or washout.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - Buvidal ARTG/PI, Sublocade Australian PI, and PBS buprenorphine modified-release injection search checked 2026-05-10 for this entry." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Partial Opioid Agonist — Partial mu-opioid agonist with extreme receptor affinity." + }, + { + "label": "Route / Formulation", + "value": "Sublingual buprenorphine products for induction/transition; depot products are healthcare-professional SC injections: Buvidal weekly/monthly and Sublocade monthly abdominal injection." + }, + { + "label": "Usual Dose & Max", + "value": "SL induction/transition is individualised. Buvidal: weekly 8-32 mg or monthly 64-160 mg. Sublocade: usually 300 mg monthly for 2 months, then 100 mg monthly; 300 mg monthly may continue if tolerated and response is inadequate." + }, + { + "label": "Key Indication Doses", + "value": "Opioid Use Disorder (Sublingual Induction): **SL** 2-4 mg STAT only when the patient is in OBJECTIVE moderate withdrawal (COWS > 12). Titrate to 16-24 mg/day. Subcutaneous Depot (Buvidal): **SC** Weekly (16-32 mg) or Monthly (64-128 mg). Does not require cold chain. Subcutaneous Depot (Sublocade): **SC** Monthly (100-300 mg) deep abdominal injection. Requires cold chain." + }, + { + "label": "Best Uses", + "value": "Buprenorphine (SL/depot) is a partial opioid agonist for opioid dependence and pain, but initiation requires mild withdrawal state and the ceiling effect limits analgesic utility in severe acute pain." + }, + { + "label": "Avoid / Cautions", + "value": "Avoid depot initiation without established buprenorphine tolerance/appropriate induction. Use caution with respiratory insufficiency, hepatic impairment, pregnancy/lactation, CNS depressants, and high-risk injection-site or diversion concerns." + }, + { + "label": "Key Risks", + "value": "Neurological: Precipitated withdrawal (if given too early). HIGH — Headache, insomnia, sweating. Gastrointestinal: Constipation, nausea. Tissue: Sublocade forms a solid lump under the skin that can be painful. Must be injected into abdominal fat." + }, + { + "label": "Key Interactions", + "value": "Full Opioid Agonists (Morphine/Oxycodone). Because buprenorphine's grip on the receptor is so tight, standard opioids will bounce off. If the patient breaks their leg, standard analgesia will fail. They require Ketamine, nerve blocks, or massive ICU-level Fentanyl doses to break through the blockade." + }, + { + "label": "Monitoring", + "value": "Before depot: confirm buprenorphine tolerance/withdrawal stability, baseline LFTs, viral hepatitis status where relevant, sedation/respiratory status, injection-site reactions, pregnancy/lactation status, and CNS depressant use." + }, + { + "label": "Clinical Pearl", + "value": "A toddler taking a sip of Methadone will die. A toddler eating a Buprenorphine tablet will likely just sleep heavily. The 'ceiling effect' means that no matter how much Buprenorphine is taken, the respiratory depression maxes out and stops before it becomes fatal." + } + ] + }, + { + "slug": "buprenorphine-naloxone", + "name": "Buprenorphine + naloxone", + "class": "Addiction", + "subclass": "Partial Opioid Agonist", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "OUD / S8", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "32 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "24–42 h", + "cls": "", + "flag": "" + }, + { + "label": "Precip. W/D", + "value": "RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Resp. Depression", + "value": "CEILING", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Buprenorphine/naloxone soluble film for opioid-dependence treatment within medical, social and psychological care. Buprenorphine provides partial mu-agonist activity; naloxone is included to reduce injection misuse.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **32 mg/day** (based on the Buprenorphine component).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Start only when withdrawal is established enough to reduce precipitated-withdrawal risk. Severe hepatic impairment is contraindicated; moderate hepatic impairment requires caution because naloxone exposure rises disproportionately.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Useful OAT option with lower overdose risk than full agonists, but induction timing, hepatic function, CNS depressants, dental effects, and acute-pain planning need active management.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Precipitated withdrawal if given while full agonists are still on the receptors. HIGH — Headache, insomnia, sweating.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Constipation, nausea.", + "tags": [] + }, + { + "key": "Dental", + "val": "HIGH — Chronic sublingual use of acidic films causes severe dental decay/cavities.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Opioid Use Disorder (Induction)", + "val": "Start only when objective opioid withdrawal is present and titrate to clinical response. Monitor closely during transfer from full agonists or methadone because buprenorphine can precipitate withdrawal if started too soon.", + "tags": [] + }, + { + "key": "Maintenance", + "val": "**SL/buccal** usual maintenance is commonly 8-24 mg/day buprenorphine; maximum is 32 mg/day. Do not substitute film strengths without prescriber approval because exposures can differ.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Suboxone", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Soluble films for sublingual or buccal administration. Supplied strengths include 2/0.5 mg and 8/2 mg in Australia; films are not designed to be split or swallowed whole.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "S8. PBS search confirms Suboxone Film listings under S100 HSD Community Access for 2/0.5 mg and 8/2 mg films; confirm current jurisdictional OAT authority and PBS restriction details before prescribing.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment for Opioid Use Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Safer than Methadone due to lower overdose risk and less QTc prolongation.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL - Contraindicated in severe respiratory insufficiency, severe hepatic impairment, and hypersensitivity to buprenorphine, naloxone, or excipients.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Suboxone PI contraindicates use in severe hepatic impairment." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION - Pregnancy category C. Use in pregnancy or lactation only after specialist benefit-risk review; avoid treating pregnancy as an absolute contraindication from the current sources.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "Pregnancy category C and lactation require benefit-risk review; not recorded here as an absolute contraindication." + } + }, + { + "key": "Renal", + "val": "CAUTION - No renal dose change is generally required, but use caution in severe renal impairment because metabolites can accumulate.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "caution", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Suboxone PI advises caution in severe renal impairment." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL - CNS depressants, alcohol, benzodiazepines, gabapentinoids and other opioids can cause profound sedation, respiratory depression, coma and death. Acute pain may need specialist strategies; do not assume high-dose opioids are safe or ineffective.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Benzodiazepines/Alcohol (Increases risk of respiratory depression).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Must use the Clinical Opiate Withdrawal Scale (COWS) before the first dose. Do not dose unless COWS > 12.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY - Check LFTs before treatment and during treatment. Use caution with moderate hepatic impairment and avoid severe hepatic impairment; assess renal status when severe impairment is present.", + "tags": [], + "patient": { + "factors": ["hepatic", "renal"], + "action": "monitor", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "Monitor LFTs and severe renal impairment risk during treatment." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Naloxone Trick", + "val": "Naloxone has low sublingual/buccal bioavailability and is included to reduce injection misuse. Avoid punitive counselling language; explain that injecting or misusing the film can precipitate withdrawal and harm.", + "tags": [] + }, + { + "key": "The Ceiling Effect", + "val": "Buprenorphine has a ceiling effect for respiratory depression compared with full agonists, but serious or fatal respiratory depression can still occur, especially with CNS depressants or non-tolerant exposure.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Buprenorphine is a high-affinity partial mu-opioid agonist. Naloxone is included to deter parenteral misuse; the film is intended for sublingual or buccal use only.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SL** 30-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "24-48 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "24-42 hours (Highly lipophilic).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - SUBOXONE ARTG 211117, Suboxone Film Australian PI, and PBS Suboxone search checked 2026-05-10 for this entry." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Partial Opioid Agonist — Sublingual partial mu-opioid agonist combined with an antagonist (Naloxone)." + }, + { + "label": "Route / Formulation", + "value": "Sublingual/buccal films (2/0.5 mg and 8/2 mg supplied in Australia). Do not swallow whole, cut, chew, or split films; allow complete dissolution." + }, + { + "label": "Usual Dose & Max", + "value": "Induct only when objective opioid withdrawal is present. Initial dosing is individualised; adjust by clinical response. Maintenance commonly 8-24 mg/day; max 32 mg/day buprenorphine." + }, + { + "label": "Key Indication Doses", + "value": "Opioid Use Disorder (Induction): **SL** 2-4 mg to start, once the patient is in OBJECTIVE moderate withdrawal (COWS score > 12). Titrate up over days. Maintenance: **SL** 8-24 mg **OD** (placed strictly under the tongue, let dissolve)." + }, + { + "label": "Best Uses", + "value": "Buprenorphine + naloxone is the standard opioid substitution therapy for opioid dependence with built-in misuse deterrent, but initiation requires the patient to be in mild withdrawal to avoid precipitated withdrawal." + }, + { + "label": "Avoid / Cautions", + "value": "Contraindicated in severe respiratory insufficiency, severe hepatic impairment, and hypersensitivity. Moderate hepatic impairment may be inappropriate and needs cautious specialist review. Use caution in severe renal impairment, pregnancy, lactation, and with CNS depressants." + }, + { + "label": "Key Risks", + "value": "Neurological: Precipitated withdrawal if given while full agonists are still on the receptors. HIGH — Headache, insomnia, sweating. Gastrointestinal: Constipation, nausea. Dental: Chronic sublingual use of acidic films causes severe dental decay/cavities." + }, + { + "label": "Key Interactions", + "value": "CNS depressants including benzodiazepines, alcohol, gabapentinoids and other opioids increase sedation, respiratory depression, coma and death risk. Full opioid agonist analgesia may be blunted but can still cause toxicity; manage acute pain with specialist input." + }, + { + "label": "Monitoring", + "value": "Monitor induction response, sedation/respiratory status, precipitated withdrawal, LFTs before and during treatment, hepatic status, renal impairment, dental health, and interacting CNS depressants." + }, + { + "label": "Clinical Pearl", + "value": "Patients often fear the Naloxone in Suboxone. Reassure them: when dissolved under the tongue, the Naloxone is 100% destroyed by first-pass metabolism. It is only there to punish them if they try to melt it down and inject it into a vein." + } + ] + }, + { + "slug": "bupropion-sr", + "name": "Bupropion SR", + "class": "SUD", + "subclass": "NDRI", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "SMOKING", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "21 h", + "cls": "", + "flag": "" + }, + { + "label": "Seizure Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Sexual Dys.", + "value": "NONE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "A noradrenaline-dopamine reuptake inhibitor approved in Australia as short-term adjunctive therapy for smoking cessation in patients committed to quitting with counselling.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg/day** (150 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Seizure risk is dose-related and patient-factor dependent. Avoid in seizure history, eating disorders, abrupt alcohol/benzodiazepine withdrawal, CNS tumour, and MAOI exposure; keep single doses at 150 mg and daily dose at 300 mg.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Bupropion SR can help smoking cessation when combined with counselling, but it is a poor fit when seizure threshold is low, eating disorder history is present, alcohol/benzodiazepine withdrawal is likely, or CYP2D6 interactions are clinically important.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Seizure risk is dose-related; PI estimates about 0.1% at sustained-release doses up to 300 mg/day. Risk rises with seizure history, eating disorders, CNS tumour, abrupt alcohol/benzodiazepine withdrawal, and other seizure-threshold-lowering factors.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Hypertension and tachycardia can occur; monitor BP, especially if combined with nicotine transdermal systems.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "LOW — Anorexia and weight loss can occur. Do not frame weight or sexual effects as guaranteed clinical benefits.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Smoking Cessation", + "val": "Start while the patient is still smoking: 150 mg daily for 3 days, then 150 mg twice daily. Separate doses by at least 8 hours; max single dose 150 mg and max daily dose 300 mg. Set quit date within the first 2 weeks, preferably week 2.", + "tags": [] + }, + { + "key": "Major Depression (Off-Label)", + "val": "Source check pending — the checked Australian PI indication is smoking cessation, not depression. Any antidepressant or augmentation use should be treated as off-label and separately source-reviewed.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zyban SR, Prexaton", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Modified-release tablet; swallow whole. Do not crush, divide, or chew.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "PBS-listed bupropion hydrochloride 150 mg modified-release tablet items exist for smoking-cessation access; confirm the current item/restriction details before prescribing.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "TGA/PBS — Short-term adjunctive therapy for nicotine dependence in patients committed to quitting, used with counselling.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Off-label note: antidepressant use or antidepressant augmentation is outside the checked Australian PI indication and needs separate source review before being presented as Australian-approved use.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Excellent for smokers who also have underlying depression or those who fear weight gain upon quitting.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Contraindicated with seizure disorder/history, CNS tumour, current or previous bulimia/anorexia nervosa, abrupt alcohol or benzodiazepine withdrawal, MAOI use within 14 days, hypersensitivity, or another bupropion-containing product.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — Pregnancy category B2; encourage quitting without pharmacotherapy where possible and use only if expected benefit outweighs risk. Lactation: bupropion/metabolites are excreted in human milk; mothers are advised not to breastfeed.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "Pregnancy category B2; lactation is not recommended in the PI because bupropion/metabolites enter milk." + } + }, + { + "key": "Renal", + "val": "CAUTION — Use reduced frequency and/or dose in renal impairment and monitor closely for adverse effects because active metabolites may accumulate.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "note": "PI advises reduced frequency and/or dose and close monitoring in renal impairment." + } + }, + { + "key": "Hepatic", + "val": "CAUTION — Mild/moderate hepatic cirrhosis requires reduced frequency. Severe hepatic cirrhosis: extreme caution; dose must not exceed 150 mg every other day.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "PI gives reduced-frequency advice for hepatic cirrhosis and a severe-cirrhosis maximum of 150 mg every other day." + } + }, + { + "key": "Paediatric", + "val": "AVOID — Safety and effectiveness are not established in patients younger than 18 years.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "caution", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "PI states safety and effectiveness are not established under 18." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Bupropion and hydroxybupropion inhibit CYP2D6. For CYP2D6 substrates with narrow therapeutic index or dose-sensitive toxicity, start low or reduce the existing medicine dose; monitor closely. Also avoid/minimise alcohol and use caution with levodopa/amantadine or seizure-threshold-lowering drugs.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MONITOR — BP, insomnia/agitation, neuropsychiatric symptoms, seizure risk factors, alcohol intake, renal/hepatic impairment, and exact dose spacing. Monitor BP more closely if combined with nicotine patches.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "monitor", + "severity": "caution", + "match": { + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "PI advises dose/frequency caution and adverse-effect monitoring in renal or hepatic impairment." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The SSRI Antidote", + "val": "Do not rely on this entry as an Australian antidepressant-switching or augmentation protocol. The checked Australian PI indication is smoking cessation; psychiatric off-label use needs separate source review.", + "tags": [] + }, + { + "key": "The Quit Date", + "val": "Start before the quit date; set the target quit date within the first 2 weeks, preferably the second week. Stop if there is no significant abstinence progress by week 7.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Bupropion selectively inhibits neuronal noradrenaline and dopamine reuptake with minimal serotonin reuptake effect; its smoking-cessation mechanism is presumed to involve noradrenergic/dopaminergic effects.", + "tags": [] + }, + { + "key": "Onset", + "val": "1-2 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "21 hours. Metabolised by CYP2B6 to active metabolite hydroxybupropion.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check — ZYBAN SR Australian PI and PBS bupropion item pages checked 2026-05-10 for this entry." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "NDRI — Noradrenaline-Dopamine Reuptake Inhibitor (NDRI)." + }, + { + "label": "Route / Formulation", + "value": "Modified-release tablets (150 mg). Swallow whole; do not crush, divide, or chew because altered release increases adverse-event/seizure risk." + }, + { + "label": "Usual Dose & Max", + "value": "Start while still smoking: 150 mg daily for 3 days, then 150 mg twice daily. Separate doses by at least 8 hours. Max single dose 150 mg; max daily dose 300 mg." + }, + { + "label": "Key Indication Doses", + "value": "Smoking cessation: set quit date within the first 2 weeks, preferably week 2. Treat at least 7 weeks; discontinue if no significant abstinence progress by week 7." + }, + { + "label": "Best Uses", + "value": "Bupropion SR is a dual-purpose antidepressant and smoking cessation aid with no sexual dysfunction or weight gain, but lowers the seizure threshold and is contraindicated in eating disorders." + }, + { + "label": "Avoid / Cautions", + "value": "Contraindicated with seizure disorder/history, CNS tumour, current/previous bulimia or anorexia, abrupt alcohol or benzodiazepine withdrawal, MAOI use within 14 days, or hypersensitivity. Reduce dose/frequency in renal or hepatic impairment; severe hepatic cirrhosis max 150 mg every other day." + }, + { + "label": "Key Risks", + "value": "Dose-related seizure risk (~0.1% up to 300 mg/day SR). Insomnia, agitation, tremor, hypertension/tachycardia, neuropsychiatric symptoms, and anorexia/weight loss can occur." + }, + { + "label": "Key Interactions", + "value": "Strong CYP2D6 inhibition: start CYP2D6 substrates at low dose or consider dose reduction. Avoid/minimise alcohol. Use caution with medicines that lower seizure threshold, levodopa/amantadine, and nicotine patches because BP can rise." + }, + { + "label": "Monitoring", + "value": "Check seizure risk factors, BP (especially with nicotine patches), renal/hepatic impairment, alcohol/benzodiazepine withdrawal risk, mood/neuropsychiatric symptoms, and adherence to dose spacing." + }, + { + "label": "Clinical Pearl", + "value": "Psychiatrists frequently add a low dose of Bupropion to a patient's SSRI regimen. The dopamine boost from Bupropion brilliantly reverses the emotional blunting and sexual dysfunction caused by the SSRI." + } + ] + }, + { + "slug": "disulfiram", + "name": "Disulfiram", + "class": "SUD", + "subclass": "ALDH Inhibitor", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "AUD", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "60-120 h", + "cls": "", + "flag": "" + }, + { + "label": "Alcohol Reaction", + "value": "FATAL RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Hepatotoxicity", + "value": "CRITICAL", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Aversive alcohol-deterrent medicine for selected motivated abstinent patients receiving counselling/psychiatric support. It does not reduce craving; it creates risk of a severe reaction if alcohol is consumed.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Maximum 300 mg/day. Maintenance is usually 200 mg/day for 6 weeks to 6 months, with review before longer-term use.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Use only with informed consent, clear abstinence, and strict counselling about hidden alcohol sources. Alcohol reactions can be severe, unpredictable, and rarely fatal.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Disulfiram is an alcohol deterrent causing severe acetaldehyde reaction with any alcohol intake, but requires strict patient motivation and compliance and has hepatotoxicity risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular / Systemic", + "val": "CRITICAL — Disulfiram-Alcohol Reaction: Throbbing headache, violent vomiting, severe flushing, dyspnea, tachycardia, hypotension, myocardial infarction, and cardiovascular collapse.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "CRITICAL — Idiosyncratic, fatal fulminant hepatitis (Can occur even without alcohol consumption).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "HIGH — Peripheral neuropathy, optic neuritis, psychosis (due to inhibition of dopamine beta-hydroxylase).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Alcohol Abstinence", + "val": "Initial: 100 mg daily for 7-14 days, then increase if required to max 300 mg/day. Maintenance is usually 200 mg daily for 6 weeks to 6 months; review effectiveness before longer-term continuation.", + "tags": [] + }, + { + "key": "Washout", + "val": "MANDATORY - Do not start until the patient has abstained from alcohol for at least 24 hours. Avoid alcohol during treatment and for at least 14 days after stopping; reactions can occur up to 3 weeks after stopping.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Antabuse", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Effervescent tablets containing disulfiram 200 mg.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "S4 prescription medicine. PBS search did not identify a disulfiram item on the checked date; recheck PBS before making subsidy/access claims.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Alcohol-deterrent aid in the overall management of selected chronic alcohol-dependent patients who are motivated to abstain and engaged in counselling/psychiatric support.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Third-line behind Acamprosate and Naltrexone. Used only when fear of violent sickness is required to stop impulsive drinking.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL - Contraindicated in pregnancy, severe myocardial disease or ischaemic heart disease, uncompensated cardiac failure, previous CVA, hypertension, advanced liver or renal disease, severe personality disorder, suicidal risk, psychosis/psychotic states, serious organic brain damage, intoxication, metronidazole/paraldehyde use, hypersensitivity, or lack of informed consent.", + "tags": [], + "patient": { + "factors": ["pregnancy", "hepatic", "renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "PI contraindicates pregnancy and advanced liver/renal disease; severe hepatic/renal patient matches should prompt avoidance." + } + }, + { + "key": "Pregnancy", + "val": "CONTRAINDICATED - Pregnancy category B2, but the PI states Antabuse should not be used in pregnancy.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Antabuse PI says it should not be used in pregnancy." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH - Alcohol and alcohol-containing preparations are contraindicated. Avoid metronidazole and paraldehyde. Monitor phenytoin levels if used together; disulfiram-alcohol reaction intensity may be increased by amitriptyline or chlorpromazine.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY - Check LFTs before treatment and periodically thereafter; fatal drug-induced liver injury has been reported. Also monitor blood count/biochemistry where prolonged therapy is used.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "monitor", + "severity": "caution", + "match": { + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "PI requires baseline and periodic liver monitoring; advanced liver disease is contraindicated." + } + }, + { + "key": "Bedside", + "val": "Educate strictly on hidden alcohols: hand sanitizer, mouthwash, perfume, kombucha, and wine sauces.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Fear Factor", + "val": "Disulfiram does not reduce craving. It works best when the patient is motivated, abstinent, fully informed, and supported by supervised administration or a structured treatment program.", + "tags": [] + }, + { + "key": "The Dopamine Psychosis", + "val": "Disulfiram also blocks dopamine beta-hydroxylase, causing dopamine to pool in the brain. This can trigger acute psychosis or severe mania in vulnerable patients.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Irreversibly inhibits Aldehyde Dehydrogenase. When alcohol is consumed, it is converted to acetaldehyde but cannot be broken down further. Acetaldehyde builds up to toxic levels in the blood, causing the 'Disulfiram Reaction'.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2-12 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "The active metabolite effect on aldehyde dehydrogenase can persist for 7-14 days after stopping; alcohol reactions may occur for up to 3 weeks.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ANTABUSE ARTG 70468, Antabuse Australian PI, and PBS disulfiram search checked 2026-05-10 for this entry." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "ALDH Inhibitor — Aldehyde dehydrogenase inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (200 mg). (Antabuse)" + }, + { + "label": "Usual Dose & Max", + "value": "Initial: 100 mg daily for 7-14 days, then increase if required to max 300 mg/day. Maintenance is usually 200 mg daily for 6 weeks to 6 months; review before longer-term use." + }, + { + "label": "Key Indication Doses", + "value": "Alcohol-deterrent therapy only for selected motivated abstinent patients in an integrated counselling/psychiatry program. Must abstain from alcohol for at least 24 h before starting and for at least 14 days after stopping; reactions may occur up to 3 weeks." + }, + { + "label": "Best Uses", + "value": "Disulfiram is an alcohol deterrent causing severe acetaldehyde reaction with any alcohol intake, but requires strict patient motivation and compliance and has hepatotoxicity risk." + }, + { + "label": "Avoid / Cautions", + "value": "Contraindicated in pregnancy, severe myocardial/ischaemic heart disease, uncompensated cardiac failure, previous CVA, hypertension, advanced liver or renal disease, psychosis/psychotic states, suicidal risk, serious organic brain damage, intoxication, metronidazole/paraldehyde use, hypersensitivity, or no informed consent." + }, + { + "label": "Key Risks", + "value": "Cardiovascular / Systemic: Disulfiram-Alcohol Reaction: Throbbing headache, violent vomiting, severe flushing, dyspnea, tachycardia, hypotension, myocardial infarction, and cardiovascular collapse. Hepatic: Idiosyncratic, fatal fulminant hepatitis (Can occur even without alcohol consumption). Neurological: Peripheral neuropathy, optic neuritis, psychosis (due to inhibition of dopamine beta-hydroxylase)." + }, + { + "label": "Key Interactions", + "value": "Alcohol and alcohol-containing products are contraindicated. Avoid metronidazole and paraldehyde. Phenytoin levels can rise; disulfiram-alcohol reaction intensity may be increased by amitriptyline or chlorpromazine. Warfarin/INR interaction should be checked locally." + }, + { + "label": "Monitoring", + "value": "Confirm informed consent and alcohol abstinence before first dose. Check LFTs before treatment and periodically; monitor for hepatitis, neuropathy, optic neuritis, mood/psychotic symptoms, and hidden alcohol exposure." + }, + { + "label": "Clinical Pearl", + "value": "Disulfiram does not reduce cravings; it works entirely on fear. It is most effective when administration is directly supervised by a spouse or clinic, ensuring the patient cannot 'choose' not to take it when they want a drink." + } + ] + }, + { + "slug": "methadone", + "name": "Methadone", + "class": "SUD", + "subclass": "Full Opioid Agonist", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "OUD / S8", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "15-60 h", + "cls": "warn", + "flag": "warn" + }, + { + "label": "QTc Risk", + "value": "DOSE-DEP", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Overdose Risk", + "value": "CRITICAL INIT.", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Long-acting full mu-opioid receptor agonist used in opioid agonist treatment and selected pain settings. Its long, variable half-life makes supervised initiation and slow titration essential.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "No simple fixed maximum for OAT; titrate under specialist/program protocol. MATOD guidance describes maintenance generally 60-100 mg, with induction increases kept slow.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Methadone accumulates because respiratory-depressant effects last longer than analgesic effects and the half-life is highly variable. Early dose increases must be conservative, with sedation/respiratory checks before escalation.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Methadone is effective but high-risk: initiation/titration, QTc risk, CNS depressant interactions, renal/hepatic impairment, pregnancy/neonatal issues, and program access rules need active management.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory", + "val": "CRITICAL — Respiratory depression is the major hazard. Peak depressant effects can persist longer than peak analgesia, so accumulation during initiation or dose conversion can cause delayed overdose.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CRITICAL — QT prolongation and torsade have been reported, particularly with higher doses and risk factors. Existing QT prolongation, including congenital long QT syndrome, is contraindicated.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "QTc risk needs ECG/electrolyte review; existing QT prolongation is contraindicated in the PI." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe constipation, sweating, weight gain.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Opioid Use Disorder (Induction)", + "val": "Initial methadone is usually 20-30 mg daily for unsanctioned opioid use; up to 40 mg may be used only with higher tolerance and supervised monitoring. Do not give additional dose for at least 3 hours after the first dose. Increase by 5-10 mg every few days if no sedation/intoxication; avoid increases >20 mg/week.", + "tags": [] + }, + { + "key": "Severe Chronic Pain", + "val": "Analgesia dosing requires careful individual conversion and monitoring. The PI warns that respiratory-depressant effects can persist longer than analgesic effects, so initiation and conversion can be fatal if titrated too quickly.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CAUTION — Do not treat methadone as simply 'safe in CKD'. The PI advises caution in renal dysfunction; for repeated analgesic dosing, increase interval to at least 8-hourly when GFR is 10-50 mL/min and at least 12-hourly when GFR is <10 mL/min.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 50 + } + }, + "note": "PI advises caution and longer intervals in renal dysfunction; apply with clinical context and local protocol." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Biodone Forte, Physeptone", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Oral liquid syrup (5 mg/mL). Tablets (10 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Methadone access depends on indication, formulation, and local OAT program rules. PBS item 13334T covers methadone hydrochloride oral liquid; confirm jurisdictional authority, supervised dosing, and dispensing requirements.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "TGA/PBS — Opioid agonist treatment for opioid dependence under supervised program arrangements; methadone products also have analgesia indications depending on formulation/product.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly effective for retaining severe addicts in treatment due to the lack of withdrawal/craving, but carries far higher toxicity risks than Buprenorphine.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Contraindicated with severe respiratory depression, MAOI use/current or within 2 weeks, severe hepatic impairment, biliary or renal tract spasm, ulcerative colitis, and existing QT prolongation including congenital long QT syndrome.", + "tags": [], + "patient": { + "factors": ["qtc", "hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 500 + }, + "hepatic": ["severe"] + }, + "note": "Existing QT prolongation and severe hepatic impairment are PI contraindications." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — Pregnancy category C; use only if benefit justifies risk. For opioid dependence, avoid abrupt destabilisation and follow specialist/OAT guidance; monitor neonates for withdrawal after maternal maintenance treatment.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Pregnancy category C; specialist/OAT context required and neonates may need withdrawal monitoring." + } + }, + { + "key": "Lactation", + "val": "CAUTION — Breastfeeding is permissible in methadone-treated mothers, but monitor the infant for sedation, respiratory depression, adequate weight gain, and withdrawal if breastfeeding stops or maternal dose changes.", + "tags": [], + "patient": { + "factors": ["lactation"], + "action": "monitor", + "severity": "caution", + "note": "PI allows breastfeeding with infant monitoring for sedation/respiratory depression and withdrawal." + } + }, + { + "key": "Hepatic", + "val": "CONTRAINDICATED — Severe hepatic impairment is contraindicated. Other hepatic impairment can slow metabolism; use less than normal dosing and titrate by response where treatment is not contraindicated.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "danger", + "match": { + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "Severe hepatic impairment is contraindicated; lesser impairment may require lower response-guided dosing." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — CYP inducers such as rifampicin, phenytoin, carbamazepine, St John's Wort, and some antiretrovirals can lower methadone exposure and precipitate withdrawal. CNS depressants increase sedation/respiratory depression; QT-prolongers and electrolyte-lowering medicines increase torsade risk.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Assess QT-risk factors and interacting medicines; obtain ECG/electrolytes where clinically indicated or high dose/risk factors are present. Existing QT prolongation, including congenital long QT, is contraindicated.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "QTc elevation or risk factors require ECG/electrolyte review before and during treatment." + } + }, + { + "key": "Bedside", + "val": "MONITOR — Check sedation, intoxication, respiratory rate, adherence/diversion risk, constipation, overdose risk, pregnancy/lactation status, renal/hepatic impairment, and concurrent CNS depressants before dose escalation.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic", "pregnancy", "lactation"], + "action": "monitor", + "severity": "caution", + "match": { + "egfr": { + "lt": 50 + }, + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "Monitor renal/hepatic impairment and pregnancy/lactation status before dose escalation." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Half-Life Trap", + "val": "Do not judge safety from early analgesic or craving response alone. Respiratory depressant effects can persist longer than analgesia, and accumulation may become evident after repeated dosing.", + "tags": [] + }, + { + "key": "The Analgesic Disconnect", + "val": "Methadone stops withdrawal for 24 hours, but it only kills pain for 6 hours. If treating chronic pain, you must dose it TDS or QID. Dosing it OD for pain will leave the patient in agony for 18 hours a day.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent full agonist at the mu-opioid receptor. Also unique among opioids: it acts as a strong NMDA receptor antagonist (providing unparalleled relief for neuropathic pain).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "24-36 h (Prevents withdrawal). 6-8 h (Analgesia).", + "tags": [] + }, + { + "key": "Half-life", + "val": "After chronic administration, half-life is about 22 hours but can range from 15 to 60 hours. This variability is why repeated dosing and titration require caution.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check — Physeptone Australian PI, PBS item 13334T, and Australian MATOD guidelines checked 2026-05-10 for this entry." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Full Opioid Agonist — Synthetic, ultra-long-acting, full mu-opioid receptor agonist." + }, + { + "label": "Route / Formulation", + "value": "Oral liquid syrup (5 mg/mL). Tablets (10 mg). (Biodone Forte, Physeptone)" + }, + { + "label": "Usual Dose & Max", + "value": "OAT induction: usually 20-30 mg daily; up to 40 mg only with higher tolerance and supervised monitoring. Avoid extra dosing for at least 3 hours; increase by 5-10 mg every few days if no sedation/intoxication. Maintenance is generally 60-100 mg." + }, + { + "label": "Key Indication Doses", + "value": "OUD: supervised induction and maintenance under OAT rules. Analgesia use follows product-specific pain dosing and requires separate careful conversion because respiratory depression lasts longer than analgesia." + }, + { + "label": "Best Uses", + "value": "Methadone is a long-acting opioid for substitution therapy and chronic pain, but has unpredictable pharmacokinetics, accumulates causing delayed respiratory depression, and prolongs QTc." + }, + { + "label": "Avoid / Cautions", + "value": "Contraindicated with severe respiratory depression, MAOI use/current or within 2 weeks, severe hepatic impairment, renal/biliary tract spasm, and existing QT prolongation/congenital long QT. Use caution in renal impairment and QT-risk states." + }, + { + "label": "Key Risks", + "value": "Delayed respiratory depression from accumulation, sedation/overdose during initiation, QT prolongation/torsade, constipation, sweating, and major interaction risk with CNS depressants, QT-prolongers, CYP inducers, and electrolyte-lowering medicines." + }, + { + "label": "Key Interactions", + "value": "CNS depressants increase sedation/respiratory depression. MAOIs are contraindicated. QT-prolongers and electrolyte-lowering medicines increase torsade risk. CYP inducers such as rifampicin, phenytoin, carbamazepine, St John's Wort, and some antiretrovirals can precipitate withdrawal." + }, + { + "label": "Monitoring", + "value": "Monitor sedation and respiratory status during initiation/titration, QTc and electrolytes where risk factors exist, constipation, adherence/diversion, hepatic impairment, renal impairment, and interacting medicines." + }, + { + "label": "Clinical Pearl", + "value": "The patient will complain on Day 2 that the 30mg dose 'isn't holding them' and demand more. You MUST say no. Because of the 40-hour half-life, that 30mg dose will organically stack in their blood, reaching the equivalent of 60mg by Day 5. If you increase the dose on Day 2, they will stop breathing on Day 5." + } + ] + }, + { + "slug": "naltrexone", + "name": "Naltrexone", + "class": "Addiction", + "subclass": "Opioid Antagonist", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "AUD / OUD", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "50 mg OD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4 h; metabolite 13 h", + "cls": "", + "flag": "" + }, + { + "label": "Hepatotoxic", + "value": "RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Opioid Block", + "value": "HIGH", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Opioid antagonist used within comprehensive treatment for alcohol dependence and as adjunctive relapse-prevention therapy after opioid cessation. It blocks opioid effects rather than directly treating withdrawal.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **50 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Confirm the patient is opioid-free for 7-10 days before starting. If opioid exposure is uncertain, use urine testing and/or a naloxone challenge; starting too early can precipitate withdrawal.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Naltrexone is useful for alcohol dependence and selected opioid-relapse prevention, but it requires verified opioid washout, careful hepatic assessment, and clear counselling about opioid blockade and overdose risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Precipitated opioid withdrawal. HIGH — Nausea, headache, dizziness, severe insomnia.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "HIGH — Acute hepatitis or liver failure is contraindicated. Active liver disease needs careful benefit-risk review; hepatocellular injury was reported with excessive doses, while 50 mg/day was not an apparent hepatotoxin in PI data.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "caution", + "severity": "caution", + "match": { + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "Active liver disease requires careful benefit-risk review; acute hepatitis or liver failure is contraindicated." + } + }, + { + "key": "Psychiatric", + "val": "MODERATE — Depression, anxiety.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Alcohol / Opioid Use Disorder", + "val": "Alcohol dependence: PO 50 mg once daily. Opioid-dependence relapse prevention: start only after opioid-free 7-10 days with no withdrawal signs; if uncertain, use a naloxone challenge or urine opioid screen before dosing.", + "tags": [] + }, + { + "key": "Sinclair Method (Off-Label)", + "val": "Source check pending — targeted/as-needed naltrexone dosing was not supported by the sources checked for this edit. Prefer the PI-supported 50 mg once-daily regimen unless separately source-reviewed.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Revia", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (50 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (STREAMLINED PBS), item 8370M, for listed alcohol-dependence and opioid-relapse-prevention restrictions. Check the current PBS restriction wording before prescribing.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "TGA/PBS — Alcohol dependence within a comprehensive treatment program; adjunctive relapse-prevention therapy in formerly opioid-dependent patients who have ceased opioids.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Weight loss (combined with bupropion).", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "AUD: useful where opioid analgesia is not needed and hepatic status is acceptable. OUD: oral naltrexone is not routine first-line maintenance because retention/compliance are poor; reserve for selected motivated/supervised patients after verified opioid cessation.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Contraindicated with opioid analgesics, current opioid dependence, acute opioid withdrawal, failed naloxone challenge or positive urine opioid screen, acute hepatitis or liver failure, and hypersensitivity.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Acute hepatitis or liver failure is contraindicated in the checked Australian PI." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — Pregnancy category B3; use only if benefit justifies risk. Lactation: use caution because excretion in human milk is unknown.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "Pregnancy category B3; lactation excretion unknown. Use only after benefit-risk review." + } + }, + { + "key": "Renal", + "val": "CAUTION — Naltrexone and its primary metabolite are excreted primarily in urine; use caution in renal impairment.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "caution", + "severity": "caution", + "note": "PI advises caution in renal impairment because naltrexone/metabolite are primarily renally excreted." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Opioid analgesia is antagonised. Attempts to overcome blockade can cause fatal overdose; emergency opioid analgesia may require higher opioid doses and closer respiratory monitoring because respiratory depression may be deeper and prolonged.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Confirm opioid-free status before initiation; check baseline and clinically indicated LFTs. Acute hepatitis or liver failure is contraindicated; active liver disease requires careful benefit-risk review.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "monitor", + "severity": "caution", + "note": "Existing row requires baseline/clinically indicated LFTs and repeats that acute hepatitis/liver failure is contraindicated." + } + }, + { + "key": "Bedside", + "val": "MONITOR — Counsel that opioid blockade changes pain-management options and overdose risk; advise patients to carry medical-alert information and warn clinicians before opioid analgesia or surgery.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Washout Rule", + "val": "Do not initiate until the patient has been opioid-free for 7-10 days and has no withdrawal signs. If uncertain, use urine opioid screen and/or naloxone challenge before treatment.", + "tags": [] + }, + { + "key": "Pain Crisis", + "val": "For planned or emergency pain care, prefer non-opioid, regional, or general anaesthesia strategies where possible. If opioids are required, higher doses and close monitoring may be needed.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitively blocks mu-opioid receptors. Alcohol releases endorphins which bind to mu-receptors to cause pleasure; Naltrexone blocks this, making drinking feel 'boring'. Also physically blocks heroin/morphine from acting.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "24-48 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Naltrexone half-life is about 4 hours; the active 6-beta-naltrexol metabolite is about 13 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check — TGA ARTG 386568, ARX-NALTREXONE Australian PI, PBS item 8370M, and Australian MATOD guidelines checked 2026-05-10 for this entry." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Opioid Antagonist — Potent, long-acting mu-opioid receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (50 mg). (Revia)" + }, + { + "label": "Usual Dose & Max", + "value": "Alcohol dependence: PO 50 mg once daily. Opioid-dependence relapse prevention: initiate only after opioid-free 7-10 days; consider 25 mg test dose then 50 mg daily if no withdrawal." + }, + { + "label": "Key Indication Doses", + "value": "AUD: 50 mg once daily within a comprehensive treatment program. OUD relapse prevention: only after verified opioid washout; urine opioid screen or naloxone challenge if uncertain." + }, + { + "label": "Best Uses", + "value": "Naltrexone is an opioid antagonist used for alcohol dependence and relapse prevention, but must have complete opioid washout before starting and is hepatotoxic at high doses." + }, + { + "label": "Avoid / Cautions", + "value": "Contraindicated with opioid analgesics, current opioid dependence, acute opioid withdrawal, positive opioid screen or failed naloxone challenge, acute hepatitis or liver failure, and hypersensitivity. Caution in renal impairment, active liver disease, pregnancy, and lactation." + }, + { + "label": "Key Risks", + "value": "Neurological: Precipitated opioid withdrawal. HIGH — Nausea, headache, dizziness, severe insomnia. Hepatic: Dose-dependent hepatotoxicity and transaminitis (usually at doses > 50mg, but monitor all patients). Psychiatric: Depression, anxiety." + }, + { + "label": "Key Interactions", + "value": "Blocks opioid analgesia. Attempts to overcome blockade can cause fatal opioid overdose; emergency opioid analgesia may require higher doses with deeper/prolonged respiratory depression. Avoid combined hepatotoxic risk unless benefit clearly outweighs risk." + }, + { + "label": "Monitoring", + "value": "Verify opioid-free 7-10 days before initiation; use urine opioid screen or naloxone challenge if uncertain. Check baseline/clinically indicated LFTs and counsel on opioid blockade/medical alert information." + }, + { + "label": "Clinical Pearl", + "value": "You must wait at least 7 days after the last short-acting opioid (or 10-14 days for methadone) before giving the first dose of Naltrexone. Perform a 'Naloxone Challenge' test first if unsure." + } + ] + }, + { + "slug": "nicotine-gum", + "name": "Nicotine gum", + "class": "SUD", + "subclass": "Nicotinic Agonist", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "NRT", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "2 mg: max 20 pieces/day; 4 mg: max 10 pieces/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "Minutes", + "cls": "", + "flag": "" + }, + { + "label": "Technique", + "value": "PARK & CHEW", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Combination", + "value": "RECOMMENDED", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Short-acting, fast-relief Nicotine Replacement Therapy. Used to combat acute, breakthrough cravings. Absorbed through the buccal mucosa, NOT the stomach.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max 20 pieces/day of 2 mg gum or 10 pieces/day of 4 mg gum.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be used with the 'Park and Chew' technique. Chewing it like normal chewing gum causes it to be swallowed, destroying the drug and causing severe hiccups and nausea.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Nicotine gum is a flexible on-demand NRT for smoking cessation allowing dose titration, but requires correct chewing technique (chew-and-park) and can cause jaw pain and GI upset.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Hiccups, severe nausea, heartburn, sore throat. (Almost exclusively caused by incorrect chewing technique leading to swallowing the nicotine).", + "tags": [] + }, + { + "key": "Dental", + "val": "MODERATE — Jaw ache, damage to dental work/fillings.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Cravings (> 20 cigs/day)", + "val": "**Buccal** 4 mg gum when cravings occur. Chew slowly until taste/tingle, then park between cheek and gum; repeat for about 30 minutes. Max 10 pieces/day.", + "tags": [] + }, + { + "key": "Acute Cravings (< 20 cigs/day)", + "val": "**Buccal** 2 mg gum when cravings occur. Chew-and-park for about 30 minutes. Max 20 pieces/day.", + "tags": [] + }, + { + "key": "Combination Therapy", + "val": "Use PRN heavily alongside a daily 24h Nicotine Patch for maximum success rates.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nicorette, Nicabate", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Chewing Gum (2 mg, 4 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Relief of acute nicotine cravings, smoking cessation adjunct.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Provides the acute 'hit' to address sudden psychological triggers (e.g., finishing a meal, feeling stressed).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CONTRAINDICATED - Do not use nicotine gum in non-tobacco users, children under 12 years, or patients with hypersensitivity to nicotine or product components.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 12 + } + }, + "note": "Existing row contraindicates this NRT product in children under 12 years; nicotine/product hypersensitivity is not modeled in the patient panel." + } + }, + { + "key": "Medical review", + "val": "Use medical review for unstable cardiovascular disease, diabetes, active GI disease, severe renal/hepatic impairment, uncontrolled hyperthyroidism, phaeochromocytoma, or seizure history.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "caution", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Existing row asks for medical review in severe renal/hepatic impairment; cardiovascular, diabetes, GI, endocrine, seizure and skin-site risks remain in row text because this panel does not model them." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION - Use during pregnancy or lactation only after risk-benefit review. Intermittent NRT may help reduce nicotine exposure timing compared with continuous forms, but smoking cessation support remains first-line.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "NRT in pregnancy/lactation requires individual risk-benefit review; intermittent forms can reduce infant exposure timing compared with continuous dosing." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CAUTION - Acidic drinks such as coffee, juice and soft drinks reduce buccal nicotine absorption; avoid them for 15 minutes before and during gum use. Smoking cessation can also increase levels of some CYP1A2 substrates such as clozapine or olanzapine.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Teach the 'Park and Chew' method. Chew slowly until a peppery taste appears. Stop chewing. 'Park' the gum between the cheek and gum until the taste fades. Chew again. Repeat for 30 minutes.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Swallowing Trap", + "val": "If swallowed, Nicotine enters the highly acidic stomach, becomes ionized, and cannot be absorbed into the blood. It then passes to the liver and is 100% destroyed. Swallowed nicotine provides zero craving relief and just makes the patient vomit.", + "tags": [] + }, + { + "key": "The Dose Confusion", + "val": "Patients often buy the 2mg gum because it's cheaper, even if they smoke 40 a day. The 2mg gum will fail miserably in a heavy smoker. Prescribe the 4mg.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Absorbed directly across the buccal mucosa into the systemic circulation, avoiding hepatic first-pass metabolism.", + "tags": [] + }, + { + "key": "Onset", + "val": "**Buccal** 5-10 mins (Rapidly hits the brain).", + "tags": [] + }, + { + "key": "Duration", + "val": "30-60 mins.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - Nicorette Chewing Gum Australian PI checked 2026-05-10 for indication, dosing limits, contraindications, pregnancy/lactation cautions, technique, acidic-drink interaction, and source-reviewed NRT safety wording." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Nicotinic Agonist — Short-acting, fast-relief Nicotine Replacement Therapy." + }, + { + "label": "Route / Formulation", + "value": "Chewing Gum (2 mg, 4 mg). (Nicorette, Nicabate)" + }, + { + "label": "Usual Dose & Max", + "value": "Use 2 mg or 4 mg gum when cravings occur. Most smokers use 8-12 pieces/day of 2 mg or 4-6 pieces/day of 4 mg. Max 20 pieces/day of 2 mg or 10 pieces/day of 4 mg." + }, + { + "label": "Key Indication Doses", + "value": "Acute Cravings (> 20 cigs/day): **Buccal** Chew 4 mg piece PRN for cravings. Max 20 pieces/day. Acute Cravings (< 20 cigs/day): **Buccal** Chew 2 mg piece PRN for cravings. Max 30 pieces/day. Combination Therapy: Use PRN heavily alongside a daily 24h Nicotine Patch for maximum success rates." + }, + { + "label": "Best Uses", + "value": "Nicotine gum is a flexible on-demand NRT for smoking cessation allowing dose titration, but requires correct chewing technique (chew-and-park) and can cause jaw pain and GI upset." + }, + { + "label": "Avoid / Cautions", + "value": "CONTRAINDICATED - Do not use nicotine gum in non-tobacco users, children under 12 years, or patients with hypersensitivity to nicotine or product components. Use medical review for pregnancy/lactation, unstable cardiovascular disease, diabetes, active GI disease, severe renal/hepatic impairment, uncontrolled hyperthyroidism, phaeochromocytoma, or seizure history." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Hiccups, severe nausea, heartburn, sore throat. (Almost exclusively caused by incorrect chewing technique leading to swallowing the nicotine). Dental: Jaw ache, damage to dental work/fillings." + }, + { + "label": "Key Interactions", + "value": "Coffee, Juice, Soft Drinks. Acidic drinks lower the pH of the mouth. Nicotine requires an alkaline pH to absorb across the cheek. If the patient drinks coffee while chewing, the absorption drops to zero. Must wait 15 mins after acidic drinks." + }, + { + "label": "Monitoring", + "value": "Teach the 'Park and Chew' method. Chew slowly until a peppery taste appears. Stop chewing. 'Park' the gum between the cheek and gum until the taste fades. Chew again. Repeat for 30 minutes." + }, + { + "label": "Clinical Pearl", + "value": "If swallowed, Nicotine enters the highly acidic stomach, becomes ionized, and cannot be absorbed into the blood. It then passes to the liver and is 100% destroyed. Swallowed nicotine provides zero craving relief and just makes the patient vomit." + } + ] + }, + { + "slug": "nicotine-inhalator", + "name": "Nicotine inhalator", + "class": "SUD", + "subclass": "Nicotinic Agonist", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "NRT", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "6 Cartridges/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "Minutes", + "cls": "", + "flag": "" + }, + { + "label": "Technique", + "value": "SHALLOW PUFFS", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Behavioral", + "value": "MIMICS SMOKING", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "A plastic mouthpiece containing a nicotine cartridge. Satisfies the 'hand-to-mouth' behavioral addiction of smoking while delivering nicotine to the mouth (not the lungs).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **6 cartridges/day** (Each cartridge lasts for about 20-40 minutes of intense puffing).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "It is NOT a vape or an asthma inhaler. The patient must take short, shallow 'cigar' puffs into the mouth. Deep lung inhalations will cause severe coughing and yield zero drug.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Nicotine inhalator is an NRT mimicking the hand-to-mouth habit of smoking, but delivers less nicotine than cigarettes and requires frequent puffing throughout the day.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Mouth/throat irritation, cough, hiccups.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Palpitations.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Cravings / Behavioral Habit", + "val": "**Buccal** Take shallow puffs continuously for 20 mins when cravings occur. Usually 3-6 cartridges a day are required.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nicorette Inhalator", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Plastic mouthpiece with replaceable 15 mg cartridges (delivers ~2-4 mg of absorbable nicotine).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Relief of acute nicotine cravings, replacement of the hand-to-mouth smoking ritual.", + "tags": ["TGA"] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CONTRAINDICATED - Do not use nicotine inhalator in non-tobacco users, children under 12 years, or patients with hypersensitivity to nicotine or product components.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 12 + } + }, + "note": "Existing row contraindicates this NRT product in children under 12 years; nicotine/product hypersensitivity is not modeled in the patient panel." + } + }, + { + "key": "Medical review", + "val": "Use medical review for unstable cardiovascular disease, diabetes, active GI disease, severe renal/hepatic impairment, uncontrolled hyperthyroidism, phaeochromocytoma, or seizure history.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "caution", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Existing row asks for medical review in severe renal/hepatic impairment; cardiovascular, diabetes, GI, endocrine, seizure and skin-site risks remain in row text because this panel does not model them." + } + }, + { + "key": "Asthma", + "val": "CAUTION - Use cautiously in chronic throat disease or asthma; nicotine vapour can irritate the throat and airways.", + "tags": [] + }, + { + "key": "Pregnancy / Lactation", + "val": "CAUTION - Use during pregnancy or lactation only after risk-benefit review. If breastfeeding and intermittent NRT is needed, feed before dosing where practical to reduce infant exposure.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "NRT in pregnancy/lactation requires individual risk-benefit review; timing breastfeeding before intermittent NRT may reduce infant exposure." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CAUTION - Acidic drinks can reduce oral nicotine absorption. Smoking cessation can increase levels of CYP1A2 substrates such as theophylline, clozapine, olanzapine, imipramine, clomipramine, fluvoxamine, ropinirole, and caffeine.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Teach the 'shallow puff' technique. If they try to inhale it like a cigarette, it will fail.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Ritual Replacement", + "val": "Many smokers are addicted to the physical act of holding a cigarette and bringing it to their lips (the ritual). The inhalator is the ONLY medical NRT that addresses this physical behavioral habit.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Air drawn through the cartridge vapourises nicotine, which is absorbed in the mouth. It is a buccal product, not a lung-delivery vape or asthma inhaler.", + "tags": [] + }, + { + "key": "Onset", + "val": "**Buccal** 5-10 mins.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - Nicorette Inhalator Australian PI checked 2026-05-10 for formulation, buccal absorption, contraindications, asthma/throat caution, renal/hepatic cautions, pregnancy/lactation, and CYP1A2 smoking-cessation interaction context." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Nicotinic Agonist — A plastic mouthpiece containing a nicotine cartridge." + }, + { + "label": "Route / Formulation", + "value": "Plastic mouthpiece with replaceable 15 mg cartridges (delivers ~2-4 mg of absorbable nicotine). (Nicorette Inhalator)" + }, + { + "label": "Usual Dose & Max", + "value": "**Buccal** Take shallow puffs continuously for 20 mins when cravings occur. Usually 3-6 cartridges a day are required. Max **6 cartridges/day** (Each cartridge lasts for about 20-40 minutes of intense puffing)." + }, + { + "label": "Best Uses", + "value": "Nicotine inhalator is an NRT mimicking the hand-to-mouth habit of smoking, but delivers less nicotine than cigarettes and requires frequent puffing throughout the day." + }, + { + "label": "Avoid / Cautions", + "value": "CONTRAINDICATED - Do not use nicotine inhalator in non-tobacco users, children under 12 years, or patients with hypersensitivity to nicotine or product components. Use medical review for pregnancy/lactation, unstable cardiovascular disease, diabetes, active GI disease, severe renal/hepatic impairment, uncontrolled hyperthyroidism, phaeochromocytoma, or seizure history." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Mouth/throat irritation, cough, hiccups. Cardiovascular: Palpitations." + }, + { + "label": "Key Interactions", + "value": "Acidic drinks (Coffee/Juice) destroy oral absorption. Wait 15 mins." + }, + { + "label": "Monitoring", + "value": "Teach the 'shallow puff' technique. If they try to inhale it like a cigarette, it will fail." + }, + { + "label": "Clinical Pearl", + "value": "Many smokers are addicted to the physical act of holding a cigarette and bringing it to their lips (the ritual). The inhalator is the ONLY medical NRT that addresses this physical behavioral habit." + } + ] + }, + { + "slug": "nicotine-lozenge", + "name": "Nicotine lozenge", + "class": "SUD", + "subclass": "Nicotinic Agonist", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "NRT", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "15 lozenges/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "Minutes", + "cls": "", + "flag": "" + }, + { + "label": "Technique", + "value": "DO NOT CHEW", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Acidic Drinks", + "value": "BLOCK ABSORPTION", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Short-acting, fast-relief Nicotine Replacement Therapy. Absorbs through the buccal mucosa. More discreet than gum and often preferred by patients with dentures.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max 15 lozenges/day.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be allowed to dissolve slowly. Chewing or swallowing it destroys the drug in the stomach and causes severe hiccups/nausea.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Nicotine lozenge is an on-demand oral NRT for smoking cessation, but must be dissolved slowly (not chewed or swallowed) and causes hiccups and throat irritation.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Hiccups, severe nausea, heartburn, sore throat (Caused by swallowing nicotine-laden saliva).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Palpitations.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Cravings (> 20 cigs/day or 1st cig within 30 mins of waking)", + "val": "**Buccal** 4 mg lozenge when cravings occur. Allow to dissolve slowly; do not chew or swallow. Max 15 lozenges/day.", + "tags": [] + }, + { + "key": "Acute Cravings (< 20 cigs/day)", + "val": "**Buccal** 2 mg lozenge when cravings occur. Allow to dissolve slowly; do not chew or swallow. Max 15 lozenges/day.", + "tags": [] + }, + { + "key": "Combination Therapy", + "val": "Best used as 'breakthrough' therapy alongside a daily 24h Nicotine Patch.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nicabate Minis, Nicorette Lozenges", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Lozenges (1.5 mg, 2 mg, 4 mg). Mini-lozenges dissolve faster.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Relief of acute nicotine cravings, smoking cessation adjunct.", + "tags": ["TGA"] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CONTRAINDICATED - Do not use nicotine lozenges in non-tobacco users, children under 12 years, or patients with hypersensitivity to nicotine or product components.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 12 + } + }, + "note": "Existing row contraindicates this NRT product in children under 12 years; nicotine/product hypersensitivity is not modeled in the patient panel." + } + }, + { + "key": "Medical review", + "val": "Use medical review for unstable cardiovascular disease, diabetes, active GI disease, severe renal/hepatic impairment, uncontrolled hyperthyroidism, phaeochromocytoma, or seizure history.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "caution", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Existing row asks for medical review in severe renal/hepatic impairment; cardiovascular, diabetes, GI, endocrine, seizure and skin-site risks remain in row text because this panel does not model them." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION - Use during pregnancy or lactation only after risk-benefit review. Prefer behavioural support first; if NRT is used, keep exposure as low as clinically effective.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "NRT in pregnancy/lactation requires individual risk-benefit review; avoid treating pregnancy as an absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CAUTION - Do not eat or drink while the lozenge is in the mouth. Acidic drinks such as coffee, juice and soft drinks can reduce buccal nicotine absorption; avoid them for about 15 minutes before use.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Teach the patient to move the lozenge from one side of the mouth to the other occasionally, and to NOT chew it.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Denture Win", + "val": "Nicotine gum is notoriously difficult for elderly patients with dentures. The lozenge provides the exact same rapid mucosal hit without sticking to dental work.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Absorbed directly across the buccal mucosa into the systemic circulation, avoiding hepatic first-pass metabolism.", + "tags": [] + }, + { + "key": "Onset", + "val": "**Buccal** 5-10 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "30-60 mins.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - Nicorette Lozenge Australian PI checked 2026-05-10 for indication, dose selection, max dose, administration technique, contraindications, cautions, and acidic-drink interaction." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Nicotinic Agonist — Short-acting, fast-relief Nicotine Replacement Therapy." + }, + { + "label": "Route / Formulation", + "value": "Lozenges (1.5 mg, 2 mg, 4 mg). Mini-lozenges dissolve faster. (Nicabate Minis, Nicorette Lozenges)" + }, + { + "label": "Usual Dose & Max", + "value": "**Buccal** 2 mg or 4 mg lozenge when cravings occur. Use 4 mg if first cigarette is within 30 minutes of waking or >20 cigarettes/day. Max 15 lozenges/day." + }, + { + "label": "Key Indication Doses", + "value": "Acute Cravings (> 20 cigs/day or 1st cig within 30 mins of waking): **Buccal** 4 mg lozenge PRN for cravings. Max 15/day. Acute Cravings (< 20 cigs/day): **Buccal** 2 mg lozenge PRN for cravings. Max 20/day. Combination Therapy: Best used as 'breakthrough' therapy alongside a daily 24h Nicotine Patch." + }, + { + "label": "Best Uses", + "value": "Nicotine lozenge is an on-demand oral NRT for smoking cessation, but must be dissolved slowly (not chewed or swallowed) and causes hiccups and throat irritation." + }, + { + "label": "Avoid / Cautions", + "value": "CONTRAINDICATED - Do not use nicotine lozenges in non-tobacco users, children under 12 years, or patients with hypersensitivity to nicotine or product components. Use medical review for pregnancy/lactation, unstable cardiovascular disease, diabetes, active GI disease, severe renal/hepatic impairment, uncontrolled hyperthyroidism, phaeochromocytoma, or seizure history." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Hiccups, severe nausea, heartburn, sore throat (Caused by swallowing nicotine-laden saliva). Cardiovascular: Palpitations." + }, + { + "label": "Key Interactions", + "value": "Coffee, Juice, Soft Drinks. Acidic drinks lower the pH of the mouth. Nicotine requires an alkaline pH to absorb. If the patient drinks coffee while the lozenge is dissolving, absorption drops to zero. Wait 15 mins after acidic drinks." + }, + { + "label": "Monitoring", + "value": "Teach the patient to move the lozenge from one side of the mouth to the other occasionally, and to NOT chew it." + }, + { + "label": "Clinical Pearl", + "value": "Nicotine gum is notoriously difficult for elderly patients with dentures. The lozenge provides the exact same rapid mucosal hit without sticking to dental work." + } + ] + }, + { + "slug": "nicotine-mouth-spray", + "name": "Nicotine mouth spray", + "class": "SUD", + "subclass": "Nicotinic Agonist", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "NRT", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "64 Sprays/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "60 SECONDS", + "cls": "good", + "flag": "" + }, + { + "label": "Technique", + "value": "DO NOT INHALE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Hiccups", + "value": "EXTREMELY COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Fast-acting oral nicotine spray for tobacco and nicotine-vaping dependence. It relieves withdrawal/craving when sprayed into the mouth, not inhaled.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2 sprays per episode**, up to **64 sprays/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Spray into the open mouth while avoiding the lips; do not inhale while spraying and do not swallow for a few seconds. Avoid eating or drinking during administration.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Nicotine mouth spray is the fastest-acting NRT for acute craving relief, but causes throat irritation and hiccups and should not be used with other oral NRT simultaneously.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Hiccups (Occurs in up to 50% of users, highly irritating). Severe burning in the throat if swallowed.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Coughing/choking if accidentally inhaled during the spray.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Cravings", + "val": "**Buccal** 1-2 sprays into the mouth when cravings strike. Max 4 sprays/hour. Max 64 sprays/day.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nicorette QuickMist", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Pump spray (1 mg/spray).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Rapid relief of acute nicotine cravings.", + "tags": ["TGA"] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CONTRAINDICATED - Do not use nicotine mouth spray in non-tobacco users, children under 12 years, or patients with hypersensitivity to nicotine or product components.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 12 + } + }, + "note": "Existing row contraindicates this NRT product in children under 12 years; nicotine/product hypersensitivity is not modeled in the patient panel." + } + }, + { + "key": "Medical review", + "val": "Use medical review for unstable cardiovascular disease, diabetes, active GI disease, severe renal/hepatic impairment, uncontrolled hyperthyroidism, phaeochromocytoma, or seizure history.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "caution", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Existing row asks for medical review in severe renal/hepatic impairment; cardiovascular, diabetes, GI, endocrine, seizure and skin-site risks remain in row text because this panel does not model them." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION - Use during pregnancy or lactation only after risk-benefit review. If NRT is needed, intermittent products may help reduce continuous nicotine exposure.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "NRT in pregnancy/lactation requires individual risk-benefit review; intermittent forms may be preferable when pharmacotherapy is needed." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Coffee, Juice, Soft Drinks. Acidic environment destroys mucosal absorption. Wait 15 mins.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY - Teach priming and mouth-spray technique: point near the open mouth, press the dispenser, avoid the lips, do not inhale while spraying, and avoid swallowing for a few seconds.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Habit Breaker", + "val": "Because the spray works in 60 seconds, it is the best NRT for a smoker who says they 'need a cigarette right now to handle stress'. It directly replaces the acute behavioral reward loop.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Ultra-rapid absorption across the highly vascularized sublingual/buccal mucosa.", + "tags": [] + }, + { + "key": "Onset", + "val": "**Buccal** 60 seconds (The closest mimic to the pharmacokinetic 'hit' of a cigarette).", + "tags": [] + }, + { + "key": "Duration", + "val": "30 mins.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - Nicorette QuickMist Australian PI checked 2026-05-10 for tobacco/vaping cessation indication, dosing limits, administration technique, contraindications, and NRT cautions." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Nicotinic Agonist — The fastest-acting NRT available." + }, + { + "label": "Route / Formulation", + "value": "Pump spray (1 mg/spray). (Nicorette QuickMist)" + }, + { + "label": "Usual Dose & Max", + "value": "**Buccal** 1-2 sprays into the mouth when cravings strike. Max 4 sprays/hour." + }, + { + "label": "Best Uses", + "value": "Nicotine mouth spray is the fastest-acting NRT for acute craving relief, but causes throat irritation and hiccups and should not be used with other oral NRT simultaneously." + }, + { + "label": "Avoid / Cautions", + "value": "CONTRAINDICATED - Do not use nicotine mouth spray in non-tobacco users, children under 12 years, or patients with hypersensitivity to nicotine or product components. Use medical review for pregnancy/lactation, unstable cardiovascular disease, diabetes, active GI disease, severe renal/hepatic impairment, uncontrolled hyperthyroidism, phaeochromocytoma, or seizure history." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Hiccups (Occurs in up to 50% of users, highly irritating). Severe burning in the throat if swallowed. Respiratory: Coughing/choking if accidentally inhaled during the spray." + }, + { + "label": "Key Interactions", + "value": "Coffee, Juice, Soft Drinks. Acidic environment destroys mucosal absorption. Wait 15 mins." + }, + { + "label": "Monitoring", + "value": "Instruct the patient to hold their breath for 2 seconds while spraying to ensure they don't inhale the mist into their trachea." + }, + { + "label": "Clinical Pearl", + "value": "Because the spray works in 60 seconds, it is the best NRT for a smoker who says they 'need a cigarette right now to handle stress'. It directly replaces the acute behavioral reward loop." + } + ] + }, + { + "slug": "nicotine-patch", + "name": "Nicotine patch", + "class": "SUD", + "subclass": "Nicotinic Agonist", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "NRT", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "25 mg/16h or 21mg/24h", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Duration", + "value": "16 or 24 h", + "cls": "good", + "flag": "" + }, + { + "label": "Vivid Dreams", + "value": "COMMON", + "cls": "warn", + "flag": "" + }, + { + "label": "Combo Rx", + "value": "RECOMMENDED", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Transdermal Nicotine Replacement Therapy (NRT). Provides a slow, steady baseline level of nicotine to prevent physical withdrawal symptoms and severe cravings.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max one 21 mg/24h patch or one 25 mg/16h patch daily. (Specialists may use 2 patches for heavy smokers).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Does not provide the 'hit' of a cigarette. Must be combined with a fast-acting NRT (gum/spray) for acute breakthrough cravings.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Nicotine patch is a steady-state NRT for smoking cessation providing continuous nicotine delivery, but vivid dreams may require daytime-only use and combination with faster-acting NRT improves success.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Insomnia, extremely vivid dreams or nightmares (if 24-hour patch is worn overnight).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "HIGH — Skin irritation, erythema, pruritus at application site (Rotate sites daily).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Palpitations, mild tachycardia (much safer than actual smoking, safe post-MI).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Smoking Cessation (> 15 cigs/day)", + "val": "**Topical** Apply one 25 mg/16 h or 21 mg/24 h patch daily according to product used, then step down. Combine with short-acting 2 mg gum/lozenge or inhalator/mouth spray for breakthrough cravings when appropriate; avoid pairing the 16 h patch with 4 mg gum/lozenge.", + "tags": [] + }, + { + "key": "Smoking Cessation (< 15 cigs/day)", + "val": "**Topical** Start at Step 2 (14 mg/24h or 15 mg/16h).", + "tags": [] + }, + { + "key": "Hospital Abstinence (Ward)", + "val": "Apply patch to prevent severe nicotine withdrawal/agitation in admitted smokers.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nicabate, Nicotinell, Nicorette", + "tags": [] + }, + { + "key": "Topical Routes", + "val": "24-hour patches (21 mg, 14 mg, 7 mg). 16-hour patches (25 mg, 15 mg, 10 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC). PBS listed for defined courses.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Smoking cessation, relief of nicotine withdrawal.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The basal backbone of cessation therapy. Best success rates when used in 'Combination NRT' (Patch + Gum/Spray).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CONTRAINDICATED - Do not use nicotine patches in non-tobacco users, children under 12 years, or patients with hypersensitivity to nicotine or patch components.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 12 + } + }, + "note": "Existing row contraindicates this NRT product in children under 12 years; nicotine/product hypersensitivity is not modeled in the patient panel." + } + }, + { + "key": "Medical review", + "val": "Use medical review for unstable cardiovascular disease, diabetes, GI disease, severe renal/hepatic impairment, uncontrolled hyperthyroidism, phaeochromocytoma, seizure history, or significant skin disease at patch sites.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "caution", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Existing row asks for medical review in severe renal/hepatic impairment; cardiovascular, diabetes, GI, endocrine, seizure and skin-site risks remain in row text because this panel does not model them." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION - Use during pregnancy or lactation only after risk-benefit review. If NRT is needed, intermittent products may be preferred over continuous patch exposure; specialist review is appropriate for ongoing patch use.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "NRT in pregnancy/lactation requires individual risk-benefit review; intermittent forms are often preferred when nicotine exposure needs minimising." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Cigarette smoke (the polycyclic aromatic hydrocarbons, NOT the nicotine) heavily induces CYP1A2. When a patient stops smoking and uses a patch, their CYP1A2 drops. Drugs like Clozapine and Olanzapine will dangerously spike in the blood. Doses must be reduced.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Rotate the patch site daily (arms, chest, back) to prevent severe skin breakdown. Apply to a hairless area.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Nightmare Fix", + "val": "If a patient on a 24-hour (21mg) patch complains of horrific, vivid nightmares, instruct them to take the patch off right before bed. The 16-hour patches (25mg) are specifically designed to be taken off at night to prevent this.", + "tags": [] + }, + { + "key": "Smoke on the Patch", + "val": "Historically, patients were told they would have a heart attack if they smoked while wearing a patch. This is a myth. The toxicity of smoking is the smoke, not the nicotine. If they slip up and have a cigarette, tell them to KEEP the patch on. Removing it guarantees full relapse.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Agonizes nicotinic acetylcholine receptors in the CNS. Satisfies the physical dependence pathway without the carcinogenic tar, carbon monoxide, or rapid dopamine 'rush' of smoking.", + "tags": [] + }, + { + "key": "Onset", + "val": "**Topical** 2-4 hours to reach steady state.", + "tags": [] + }, + { + "key": "Duration", + "val": "16 or 24 hours (depending on patch type).", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-2 hours after removal.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - Nicorette 16hr Invisipatch Australian PI checked 2026-05-10 for patch dosing, combination NRT limits, contraindications, cautions, and source-reviewed patch counselling." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Nicotinic Agonist — Transdermal Nicotine Replacement Therapy (NRT)." + }, + { + "label": "Route / Formulation", + "value": "24-hour patches (21 mg, 14 mg, 7 mg). 16-hour patches (25 mg, 15 mg, 10 mg). (Nicabate, Nicotinell, Nicorette)" + }, + { + "label": "Usual Dose & Max", + "value": "**Topical** Apply one Step 1 patch (21 mg/24h or 25 mg/16h) daily for 4-8 weeks. Then step down to 14 mg, then 7 mg over weeks. Max one 21 mg/24h patch or one 25 mg/16h patch daily. (Specialists may use 2 patches for heavy smokers)." + }, + { + "label": "Key Indication Doses", + "value": "Smoking Cessation (> 15 cigs/day): **Topical** Apply one Step 1 patch (21 mg/24h or 25 mg/16h) daily for 4-8 weeks. Then step down to 14 mg, then 7 mg over weeks. Smoking Cessation (< 15 cigs/day): **Topical** Start at Step 2 (14 mg/24h or 15 mg/16h). Hospital Abstinence (Ward): Apply patch to prevent severe nicotine withdrawal/agitation in admitted smokers." + }, + { + "label": "Best Uses", + "value": "Nicotine patch is a steady-state NRT for smoking cessation providing continuous nicotine delivery, but vivid dreams may require daytime-only use and combination with faster-acting NRT improves success." + }, + { + "label": "Avoid / Cautions", + "value": "Contraindicated in non-tobacco users, children under 12 years, or hypersensitivity to nicotine/components. Use medical review for pregnancy/lactation, unstable cardiovascular disease, diabetes, GI disease, severe renal/hepatic impairment, uncontrolled hyperthyroidism, phaeochromocytoma, seizure history, or significant skin disease at application sites." + }, + { + "label": "Key Risks", + "value": "Neurological: Insomnia, extremely vivid dreams or nightmares (if 24-hour patch is worn overnight). Dermatological: Skin irritation, erythema, pruritus at application site (Rotate sites daily). Cardiovascular: Palpitations, mild tachycardia (much safer than actual smoking, safe post-MI)." + }, + { + "label": "Key Interactions", + "value": "Cigarette smoke (the polycyclic aromatic hydrocarbons, NOT the nicotine) heavily induces CYP1A2. When a patient stops smoking and uses a patch, their CYP1A2 drops. Drugs like Clozapine and Olanzapine will dangerously spike in the blood. Doses must be reduced." + }, + { + "label": "Monitoring", + "value": "Rotate the patch site daily (arms, chest, back) to prevent severe skin breakdown. Apply to a hairless area." + }, + { + "label": "Clinical Pearl", + "value": "If a patient on a 24-hour (21mg) patch complains of horrific, vivid nightmares, instruct them to take the patch off right before bed. The 16-hour patches (25mg) are specifically designed to be taken off at night to prevent this." + } + ] + }, + { + "slug": "nicotine-sublingual-tablet", + "name": "Nicotine sublingual tablet", + "class": "SUD", + "subclass": "Nicotinic Agonist", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "NRT", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "40 Tabs/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "Minutes", + "cls": "", + "flag": "" + }, + { + "label": "Technique", + "value": "UNDER TONGUE", + "cls": "warn", + "flag": "" + }, + { + "label": "Discreet", + "value": "HIGHLY", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Tiny microtabs that dissolve completely under the tongue. The most discreet form of NRT available (no chewing or spraying required).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **40 tablets/day** (2mg).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must not be swallowed. Must sit under the tongue until fully dissolved.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Nicotine sublingual tablet is a discreet sublingual NRT for smoking cessation, but requires correct placement under the tongue and causes mouth irritation.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Burning sensation under the tongue, hiccups, nausea (if swallowed).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Cravings", + "val": "**SL** 1-2 tablets (2 mg) placed under the tongue every 1-2 hours PRN. Max 40 tablets/day.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nicorette Microtab", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Sublingual tablets (2 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Relief of acute nicotine cravings.", + "tags": ["TGA"] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "NONE.", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Acidic drinks destroy oral absorption. Wait 15 mins.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Ensure the patient does not swallow the tablet.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Professional Choice", + "val": "Excellent for patients who cannot be seen chewing gum or using a spray at work (e.g., teachers, customer service). The microtab sits silently under the tongue.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Absorbed directly across the sublingual mucosa into the systemic circulation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SL** 5-10 mins.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - healthdirect NICORETTE MICROTAB Australian medicine record checked 2026-05-12 for ARTG-derived identity, formulation, indication, schedule/access, pregnancy-advice context, and source-row status. Exact public Australian PI remains a source gap for deeper clinical rewrites." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Nicotinic Agonist — Tiny microtabs that dissolve completely under the tongue." + }, + { + "label": "Route / Formulation", + "value": "Sublingual tablets (2 mg). (Nicorette Microtab)" + }, + { + "label": "Usual Dose & Max", + "value": "**SL** 1-2 tablets (2 mg) placed under the tongue every 1-2 hours PRN. Max 40 tablets/day." + }, + { + "label": "Best Uses", + "value": "Nicotine sublingual tablet is a discreet sublingual NRT for smoking cessation, but requires correct placement under the tongue and causes mouth irritation." + }, + { + "label": "Avoid / Cautions", + "value": "NONE." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Burning sensation under the tongue, hiccups, nausea (if swallowed)." + }, + { + "label": "Key Interactions", + "value": "Acidic drinks destroy oral absorption. Wait 15 mins." + }, + { + "label": "Monitoring", + "value": "Ensure the patient does not swallow the tablet." + }, + { + "label": "Clinical Pearl", + "value": "Excellent for patients who cannot be seen chewing gum or using a spray at work (e.g., teachers, customer service). The microtab sits silently under the tongue." + } + ] + }, + { + "slug": "varenicline", + "name": "Varenicline", + "class": "SUD", + "subclass": "Nicotinic Partial Agonist", + "category": "Addiction Medicine", + "accent": "#e11d48", + "tag": "SMOKING", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1 mg BD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "24 h", + "cls": "", + "flag": "" + }, + { + "label": "Nausea", + "value": "COMMON", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Neuropsych Risk", + "value": "MONITOR", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Selective alpha-4-beta-2 nicotinic receptor partial agonist used as an aid to smoking cessation in adults. It reduces withdrawal/craving and blunts nicotine reward if smoking occurs.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2 mg/day** (1 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Use varenicline with a quit plan and behavioural support. Monitor for serious mood, behaviour, suicidal-ideation, seizure, and tolerability problems; do not present EAGLES or any single trial as proving universal psychiatric safety.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Varenicline is a highly effective smoking-cessation medicine when paired with counselling/support, but renal dosing, neuropsychiatric monitoring, seizure history, nausea, sleep disturbance, and PBS course rules need active review.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea is common and dose-limiting for some patients. Taking tablets after food with a full glass of water improves tolerability.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Extremely vivid, bizarre, or terrifying dreams. Insomnia, headache.", + "tags": [] + }, + { + "key": "Psychiatric", + "val": "MONITOR — Mood changes, agitation, behaviour change and suicidal ideation have been reported during smoking cessation and varenicline treatment. Stop and reassess urgently if serious symptoms emerge.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Smoking Cessation (Titration)", + "val": "Days 1-3: **PO** 0.5 mg **OD**. Days 4-7: **PO** 0.5 mg **BD**. Day 8 onward: **PO** 1 mg **BD** for 12 weeks.", + "tags": [] + }, + { + "key": "The Quit Date", + "val": "MONITOR — Set a target quit date and usually start varenicline 1-2 weeks beforehand. Some patients may use a flexible quit date or gradual reduction approach if abrupt cessation is not suitable.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Severe renal impairment: start 0.5 mg daily and do not exceed 0.5 mg twice daily. End-stage renal disease/on haemodialysis: max 0.5 mg daily if tolerated. No hepatic dose adjustment is expected.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Severe renal impairment requires varenicline dose reduction; ESRD max is lower." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Champix", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (0.5 mg, 1 mg). Take strictly after food with a full glass of water to prevent severe nausea.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "S4. Authority Required (STREAMLINED PBS) varenicline tablet items are listed for smoking cessation; check current PBS restrictions, course limits, counselling/support requirements, and spacing from bupropion or repeat varenicline courses.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Smoking cessation in adults.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line option for adults ready to stop smoking when renal function, neuropsychiatric history, seizure risk, pregnancy/lactation, and tolerability are acceptable. Pair with behavioural support; do not combine with NRT routinely without review.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CONTRAINDICATED — Known hypersensitivity to varenicline or excipients. Other major cautions are handled in the dedicated caution, monitoring, and interaction rows.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — Pregnancy category B3; use only if the expected benefit justifies fetal risk. Prefer non-drug support first and consider alternatives after individual risk-benefit review.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "Pregnancy category B3; lactation/pregnancy require individual benefit-risk review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CAUTION — Transdermal NRT co-administration increased adverse effects in study data. Avoid routine combination unless there is a clear plan to monitor nausea, headache, vomiting, dizziness, dyspepsia, fatigue, and overall tolerability.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "LOW — Varenicline has minimal clinically meaningful CYP450 interaction burden and is largely renally excreted unchanged; renal function matters more than CYP-mediated interactions.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Review mood, behaviour change, suicidal ideation, agitation, sleep disturbance, nausea, seizure symptoms, adherence, and quit progress. Stop and reassess if serious neuropsychiatric or seizure symptoms occur.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — Check renal function before selecting dose and re-check if renal status changes. Hepatic dose adjustment is not expected.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "monitor", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Renal function determines dose reduction in severe impairment and ESRD." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Nausea Fix", + "val": "Take varenicline after food with a full glass of water; dose reduction can be considered if nausea is not tolerated.", + "tags": [] + }, + { + "key": "The Cigarette Tastes Bad", + "val": "Warn the patient that during Week 1 (while they are still smoking), cigarettes will start to taste 'metallic', 'boring', or 'gross'. This means the receptor is successfully blocked and the drug is working.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Partial agonist at alpha-4-beta-2 nicotinic receptors: provides enough agonist activity to reduce craving/withdrawal while reducing the reinforcing effect of nicotine from cigarettes.", + "tags": [] + }, + { + "key": "Onset", + "val": "Begin 1-2 weeks before the target quit date; alternative flexible quit-date or gradual-reduction approaches may be used when abrupt cessation is not suitable.", + "tags": [] + }, + { + "key": "Half-life", + "val": "24 hours. Excreted >90% unchanged in urine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check — Varenicline Australian PI, PBS item records, and PBAC smoking-cessation restriction context checked 2026-05-10 for this entry." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Nicotinic Partial Agonist — Highly selective partial agonist at the alpha-4-beta-2 nicotinic receptor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (0.5 mg, 1 mg). Take strictly after food with a full glass of water to prevent severe nausea. (Champix)" + }, + { + "label": "Usual Dose & Max", + "value": "Days 1-3: PO 0.5 mg daily. Days 4-7: 0.5 mg twice daily. Day 8 onward: 1 mg twice daily for 12 weeks. Take after food with water. Max 2 mg/day; reduce dose in severe renal impairment." + }, + { + "label": "Key Indication Doses", + "value": "Set a target quit date and usually start varenicline 1-2 weeks before it. If abrupt quitting is not suitable, use a flexible quit date or gradual reduction plan supported by the PI rather than telling the patient they must continue smoking." + }, + { + "label": "Best Uses", + "value": "Varenicline is the most effective single-agent pharmacotherapy for smoking cessation, but causes vivid dreams and nausea and was previously (though no longer) flagged for neuropsychiatric risk." + }, + { + "label": "Avoid / Cautions", + "value": "Contraindicated in hypersensitivity. Use caution with severe renal impairment, end-stage renal disease, seizure history, significant neuropsychiatric symptoms, pregnancy, and lactation; monitor mood and behaviour during treatment." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea (up to 30% of patients. Often the main reason for quitting the drug). Neurological: Extremely vivid, bizarre, or terrifying dreams. Insomnia, headache. Psychiatric: Depression, agitation, suicidal ideation (Risk exists, but largely attributed to the psychological trauma of nicotine withdrawal rather than the drug itself)." + }, + { + "label": "Key Interactions", + "value": "Minimal CYP450 interaction burden. Combining with transdermal nicotine replacement can increase adverse effects such as nausea, headache, vomiting, dizziness, dyspepsia, and fatigue; use combination only with clear review." + }, + { + "label": "Monitoring", + "value": "Check renal function before dose selection. Monitor mood, behaviour change, agitation, depressed mood, suicidal ideation, seizures, nausea, sleep disturbance, and smoking-cessation progress." + }, + { + "label": "Clinical Pearl", + "value": "Taking the tablet on an empty stomach guarantees severe nausea. Taking it immediately after a large meal with a full 250mL glass of water drastically reduces this." + } + ] + }, + { + "slug": "adrenaline-epinephrine", + "name": "Adrenaline / Epinephrine", + "class": "Emergency", + "subclass": "Alpha/Beta Agonist", + "category": "Allergy & Anaphylaxis", + "accent": "#e11d48", + "tag": "SYMPATHOMIMETIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "No Max in Arrest", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-3 mins", + "cls": "", + "flag": "" + }, + { + "label": "Route", + "value": "IM Anaphylaxis", + "cls": "purple", + "flag": "" + }, + { + "label": "Route", + "value": "IV Arrest", + "cls": "purple", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent, direct-acting alpha and beta adrenoceptor agonist. The universal, immediate life-saving drug for anaphylaxis and cardiac arrest.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "No absolute maximum in life-threatening emergencies. Titrate to effect.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The route determines the dilution. Anaphylaxis is strictly 1:1,000 given **IM**. Cardiac arrest is strictly 1:10,000 given **IV**.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Adrenaline / Epinephrine is the only first-line treatment for anaphylaxis and cardiac arrest, but IV use requires extreme caution with dilution and must be distinguished from the IM auto-injector dose.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Tachycardia, severe hypertension, arrhythmias (VF/VT), myocardial ischaemia.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Tremor, severe anxiety, headache.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hyperglycemia, lactic acidosis (Type B), hypokalemia (due to Beta-2 shift).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Anaphylaxis", + "val": "**IM** 500 micrograms (0.5 mL of 1:1,000 solution) into the anterolateral thigh; repeat every 5 mins PRN. For community devices, use weight-based autoinjector/nasal-spray guidance and train the patient/carer.", + "tags": [] + }, + { + "key": "Cardiac Arrest (VF/pVT)", + "val": "**IV** 1 mg (10 mL of 1:10,000 solution) every 3-5 mins during CPR.", + "tags": [] + }, + { + "key": "Severe Asthma / Croup", + "val": "**Inhaled** 5 mg via nebuliser (temporising).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "EpiPen, Adrenaline Min-I-Jet", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules 1:1,000 (1 mg/1 mL). Prefilled syringes 1:10,000 (1 mg/10 mL). EpiPen (300 mcg autoinjector).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Adrenaline autoinjectors are S3 and available without prescription; EpiPen/Anapen devices are PBS-listed where criteria are met. Specify device brand/no substitution and provide an ASCIA action plan and device training.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Anaphylaxis, Cardiac Arrest, severe bradycardia, profound shock.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Immediate administration is the single most important intervention in anaphylaxis.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "NONE — There are zero absolute contraindications to adrenaline in a life-threatening anaphylaxis or cardiac arrest scenario.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CAUTION — Extreme caution if giving IV in patients with severe ischaemic heart disease (if not in arrest).", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Non-selective beta-blockers (Propranolol). They block the beta-2 vasodilation of adrenaline, leaving alpha-1 vasoconstriction unopposed, causing massive, lethal hypertensive spikes.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Continuous **ECG**, **SpO2**, and **BP** monitoring post-administration. Watch for rebound anaphylaxis as the drug wears off.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Thigh Rule", + "val": "IM Adrenaline MUST be injected into the vastus lateralis (anterolateral mid-third of the thigh). Blood flow here is massive; it absorbs much faster than from the deltoid or glutes.", + "tags": [] + }, + { + "key": "The Dilution Error", + "val": "Giving 1:1,000 (1 mg/1 mL) directly **IV** to a patient with a pulse will cause immediate catastrophic hypertension, intracranial haemorrhage, and VF. IV doses must be 1:10,000 or highly diluted infusions.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Alpha-1 (intense vasoconstriction, restores BP, reduces mucosal oedema). Beta-1 (increases HR and contractility). Beta-2 (bronchodilation, blocks mast cell degranulation).", + "tags": [] + }, + { + "key": "Onset", + "val": "**IM** 3-5 mins. **IV** Immediate.", + "tags": [] + }, + { + "key": "Duration", + "val": "Short-lived (5-10 mins).", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 minutes. Rapidly degraded by MAO and COMT.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: EPIPEN/ADRENALINE VIATRIS Australian PI/CMI and ASCIA adrenaline-device guidance source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha/Beta Agonist — Potent, direct-acting alpha and beta adrenoceptor agonist." + }, + { + "label": "Route / Formulation", + "value": "Ampoules 1:1,000 (1 mg/1 mL). Prefilled syringes 1:10,000 (1 mg/10 mL). EpiPen (300 mcg autoinjector). (EpiPen, Adrenaline Min-I-Jet)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 500 mcg (0.5 mL of 1:1,000 solution) into the anterolateral thigh. Repeat every 5 mins PRN. No absolute maximum in life-threatening emergencies. Titrate to effect." + }, + { + "label": "Key Indication Doses", + "value": "Anaphylaxis: **IM** 500 mcg (0.5 mL of 1:1,000 solution) into the anterolateral thigh. Repeat every 5 mins PRN. Cardiac Arrest (VF/pVT): **IV** 1 mg (10 mL of 1:10,000 solution) every 3-5 mins during CPR. Severe Asthma / Croup: **Inhaled** 5 mg via nebuliser (temporising)." + }, + { + "label": "Best Uses", + "value": "Adrenaline / Epinephrine is the only first-line treatment for anaphylaxis and cardiac arrest, but IV use requires extreme caution with dilution and must be distinguished from the IM auto-injector dose." + }, + { + "label": "Avoid / Cautions", + "value": "No absolute contraindication in life-threatening anaphylaxis. Use caution with IV adrenaline outside cardiac arrest or specialist settings; dosing-route errors can cause catastrophic hypertension and arrhythmia." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Tachycardia, severe hypertension, arrhythmias (VF/VT), myocardial ischaemia. Neurological: Tremor, severe anxiety, headache. Metabolic: Hyperglycemia, lactic acidosis (Type B), hypokalemia (due to Beta-2 shift)." + }, + { + "label": "Key Interactions", + "value": "Non-selective beta-blockers (Propranolol). They block the beta-2 vasodilation of adrenaline, leaving alpha-1 vasoconstriction unopposed, causing massive, lethal hypertensive spikes." + }, + { + "label": "Monitoring", + "value": "Continuous **ECG**, **SpO2**, and **BP** monitoring post-administration. Watch for rebound anaphylaxis as the drug wears off." + }, + { + "label": "Clinical Pearl", + "value": "IM Adrenaline MUST be injected into the vastus lateralis (anterolateral mid-third of the thigh). Blood flow here is massive; it absorbs much faster than from the deltoid or glutes." + } + ] + }, + { + "slug": "cetirizine", + "name": "Cetirizine", + "class": "Allergy", + "subclass": "H1 Antihistamine (2nd Gen)", + "category": "Allergy & Anaphylaxis", + "accent": "#e11d48", + "tag": "ANTIHISTAMINE", + "schedule": "S2", + "stats": [ + { + "label": "Dose", + "value": "10 mg OD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "8 h", + "cls": "", + "flag": "" + }, + { + "label": "Sedation", + "value": "MILD", + "cls": "warn", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Second-generation H1-receptor antagonist. Highly effective for allergic rhinitis and urticaria. 'Non-sedating', but actually the most sedating of the 2nd-gen class.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day** (Standard dose 10 mg).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Preferred for intense acute urticaria as it works rapidly, but warn patients it may cause mild drowsiness.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Cetirizine is a reliable second-generation antihistamine for allergic rhinitis and urticaria, but causes mild sedation in some patients despite being classified as non-sedating.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "MODERATE — Drowsiness, fatigue (Occurs in ~14% of patients, highest among 2nd gen antihistamines).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Dry mouth (very minimal anticholinergic effect).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Allergic Rhinitis / Urticaria", + "val": "**PO** 10 mg **OD**.", + "tags": [] + }, + { + "key": "Severe Urticaria", + "val": "**PO** 10 mg **BD** (Off-label specialist escalation).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce dose to 5 mg OD if **eGFR** 10-30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zyrtec, Zilarex", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg), Oral liquid (1 mg/mL), Oral drops (10 mg/mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S2). PBS listed for specific chronic conditions.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Seasonal allergic rhinitis, chronic idiopathic urticaria.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line antihistamine when rapid onset is required and mild sedation is acceptable or desired (e.g., nighttime itching).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal impairment without dose adjustment.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2. (Loratadine is typically preferred).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Cetirizine pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "MODERATE — Additive CNS depression if combined with alcohol or sedatives (due to slight BBB penetration).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Warn against driving or operating machinery until they know how the drug affects them.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** in the elderly before prescribing.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 'Non-Sedating' Myth", + "val": "Cetirizine is the active metabolite of hydroxyzine (a heavily sedating 1st-gen antihistamine). It crosses the blood-brain barrier just enough to cause drowsiness in 1 in 7 people. Prescribe at **NOCTE** to utilize this for sleep.", + "tags": [] + }, + { + "key": "Renal Clearance", + "val": "Unlike Loratadine/Fexofenadine which are hepatic, Cetirizine relies on the kidneys. Dose must be halved in severe CKD.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive, highly selective antagonist of the peripheral H1 histamine receptor. Stabilizes mast cells.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 20-60 mins (Very fast for oral).", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "8 hours. Excreted largely unchanged in urine (requires renal adjustment).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ALZENE/cetirizine Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "H1 Antihistamine (2nd Gen) — Second-generation H1-receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg), Oral liquid (1 mg/mL), Oral drops (10 mg/mL). (Zyrtec, Zilarex)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10 mg **OD**. Max **20 mg/day** (Standard dose 10 mg)." + }, + { + "label": "Key Indication Doses", + "value": "Allergic Rhinitis / Urticaria: **PO** 10 mg **OD**. Severe Urticaria: **PO** 10 mg **BD** (Off-label specialist escalation). Renal Impairment: Reduce dose to 5 mg OD if **eGFR** 10-30." + }, + { + "label": "Best Uses", + "value": "Cetirizine is a reliable second-generation antihistamine for allergic rhinitis and urticaria, but causes mild sedation in some patients despite being classified as non-sedating." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal impairment without dose adjustment. **Pregnancy** Category B2. (Loratadine is typically preferred)." + }, + { + "label": "Key Risks", + "value": "Neurological: Drowsiness, fatigue (Occurs in ~14% of patients, highest among 2nd gen antihistamines). Gastrointestinal: Dry mouth (very minimal anticholinergic effect)." + }, + { + "label": "Key Interactions", + "value": "Additive CNS depression if combined with alcohol or sedatives (due to slight BBB penetration)." + }, + { + "label": "Monitoring", + "value": "Warn against driving or operating machinery until they know how the drug affects them. Check **eGFR** in the elderly before prescribing." + }, + { + "label": "Clinical Pearl", + "value": "Cetirizine is the active metabolite of hydroxyzine (a heavily sedating 1st-gen antihistamine). It crosses the blood-brain barrier just enough to cause drowsiness in 1 in 7 people. Prescribe at **NOCTE** to utilize this for sleep." + } + ] + }, + { + "slug": "diphenhydramine", + "name": "Diphenhydramine", + "class": "Sedative", + "subclass": "H1 Antihistamine (1st Gen)", + "category": "Allergy & Anaphylaxis", + "accent": "#e11d48", + "tag": "ANTIHISTAMINE", + "schedule": "S3", + "stats": [ + { + "label": "Max Dose", + "value": "Sleep: 50 mg nocte", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-8 h", + "cls": "", + "flag": "" + }, + { + "label": "Anticholinergic", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "PROFOUND", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "First-generation H1 antihistamine. Highly lipophilic, easily crossing the blood-brain barrier. Causes profound sedation and intense anticholinergic effects.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg/day** (Usually given as 25-50 mg per dose).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Extremely dangerous in the frail elderly due to massive risk of delirium, falls, and acute urinary retention.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Diphenhydramine is a first-generation antihistamine for allergic reactions and short-term insomnia, but has potent anticholinergic effects making it dangerous in elderly and causes significant next-day sedation.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Toxic delirium, confusion, hallucinations (especially in elderly or overdose). HIGH — Next-day hangover, profound sedation, impaired motor skills.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe dry mouth, constipation.", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "CRITICAL — Acute urinary retention (precipitates retention in men with BPH).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Insomnia (Short-term)", + "val": "**PO** 50 mg 20 minutes before bed when necessary. Use only for a few days at a time; persistent insomnia requires medical review.", + "tags": [] + }, + { + "key": "Severe Allergic Reactions", + "val": "**PO** / **IV** / **IM** 25-50 mg q6-8h PRN.", + "tags": [] + }, + { + "key": "Acute Dystonia (Antipsychotic-induced)", + "val": "**IV** / **IM** 25-50 mg STAT (if Benzatropine is unavailable).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Benadryl (Sleep/Allergy formulations), Snuza", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets (25 mg, 50 mg). Oral liquid.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** / **IM** use (Mostly used in EDs/OTs).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S3).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Short-term insomnia, allergic rhinitis, acute urticaria/allergic reactions, motion sickness.", + "tags": ["TGA"] + }, + { + "key": "Off-Label", + "val": "Acute dystonic reactions (muscle spasms caused by Haldol/Maxolon), EPS management.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Primarily used as an OTC sleep aid or a rapid rescue agent for dystonia/anaphylaxis in the ED.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Hypersensitivity, newborn infants, severe hepatic/renal/respiratory insufficiency. Use caution with angle-closure glaucoma, bladder neck obstruction/urinary retention, symptomatic prostatic hypertrophy, asthma/chronic bronchitis, stenosing peptic ulcer, pyloroduodenal obstruction, porphyria, and epilepsy.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Diphenhydramine is contraindicated in severe hepatic, renal, or respiratory insufficiency and needs caution in obstructive/anticholinergic-risk states." + } + }, + { + "key": "Elderly", + "val": "AVOID — Older adults have increased susceptibility to sedation, anticholinergic effects, delirium, urinary retention, and falls; avoid use for sleep and use only with clear justification and close monitoring.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "caution", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Older adults are more susceptible to diphenhydramine sedation and anticholinergic toxicity." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — Pregnancy Category A; therapeutic doses are considered unlikely to pose substantial teratogenic risk, but use only when needed and avoid routine sleep-aid use without review.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Diphenhydramine pregnancy exposure should prompt benefit-risk review, not an automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Alcohol, opioids, benzodiazepines, barbiturates, antipsychotics, and other sedatives enhance CNS depression; MAOIs, TCAs, and atropine-like medicines intensify anticholinergic effects.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — TCAs, Antipsychotics, Oxybutynin (Massive additive anticholinergic toxidrome).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor bladder output in older patients. Ensure a clear path to the bathroom to prevent falls.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Dystonia Rescue", + "val": "If a young patient is given IV Metoclopramide (Maxolon) for nausea and suddenly develops a locked jaw or their neck violently spasms backward (oculogyric crisis), they are having an acute dystonic reaction. 50mg of IV/IM Diphenhydramine (or Benzatropine) will cure the spasm in 60 seconds by resetting the dopamine-acetylcholine balance in the brain.", + "tags": [] + }, + { + "key": "The Paradoxical Excitement", + "val": "In toddlers and children, Diphenhydramine often has the exact *opposite* effect. Instead of putting them to sleep, it acts as a stimulant, causing hyperactive, bouncing-off-the-walls manic behavior. Warn parents using it for long flights.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive antagonist at peripheral and central H1 histamine receptors. Strong antagonist at central muscarinic (M1) receptors (providing its anti-Parkinsonian/anti-dystonic effects).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 15-30 mins. **IV** Immediate.", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-8 hours. Extensively hepatically metabolised by CYP2D6.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: SNUZAID/Benadryl diphenhydramine Australian PI/CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "H1 Antihistamine (1st Gen) — First-generation H1 antihistamine." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets (25 mg, 50 mg). Oral liquid. (Benadryl (Sleep/Allergy formulations), Snuza)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 25-50 mg **NOCTE** (taken 30 mins before bed). Max **300 mg/day** (Usually given as 25-50 mg per dose)." + }, + { + "label": "Key Indication Doses", + "value": "Insomnia (Short-term): **PO** 25-50 mg **NOCTE** (taken 30 mins before bed). Severe Allergic Reactions: **PO** / **IV** / **IM** 25-50 mg q6-8h PRN. Acute Dystonia (Antipsychotic-induced): **IV** / **IM** 25-50 mg STAT (if Benzatropine is unavailable)." + }, + { + "label": "Best Uses", + "value": "Diphenhydramine is a first-generation antihistamine for allergic reactions and short-term insomnia, but has potent anticholinergic effects making it dangerous in elderly and causes significant next-day sedation." + }, + { + "label": "Avoid / Cautions", + "value": "Narrow-angle glaucoma, severe BPH, acute asthma attack (dries up respiratory secretions into thick mucus plugs). **Pregnancy** Category A (Safe, but newer 2nd gen agents like Loratadine are preferred)." + }, + { + "label": "Key Risks", + "value": "Neurological: Toxic delirium, confusion, hallucinations (especially in elderly or overdose). HIGH — Next-day hangover, profound sedation, impaired motor skills. Gastrointestinal: Severe dry mouth, constipation. Genitourinary: Acute urinary retention (precipitates retention in men with BPH)." + }, + { + "label": "Key Interactions", + "value": "Additive CNS depression with Opioids, Benzos, and Alcohol (frequent cause of accidental overdose). TCAs, Antipsychotics, Oxybutynin (Massive additive anticholinergic toxidrome)." + }, + { + "label": "Monitoring", + "value": "Monitor bladder output in older patients. Ensure a clear path to the bathroom to prevent falls. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "If a young patient is given IV Metoclopramide (Maxolon) for nausea and suddenly develops a locked jaw or their neck violently spasms backward (oculogyric crisis), they are having an acute dystonic reaction. 50mg of IV/IM Diphenhydramine (or Benzatropine) will cure the spasm in 60 seconds by resetting the dopamine-acetylcholine balance in the brain." + } + ] + }, + { + "slug": "fexofenadine", + "name": "Fexofenadine", + "class": "Allergy", + "subclass": "H1 Antihistamine (2nd Gen)", + "category": "Allergy & Anaphylaxis", + "accent": "#e11d48", + "tag": "ANTIHISTAMINE", + "schedule": "S2", + "stats": [ + { + "label": "Max Dose", + "value": "180 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "14 h", + "cls": "", + "flag": "" + }, + { + "label": "Sedation", + "value": "NONE", + "cls": "good", + "flag": "" + }, + { + "label": "Juice", + "value": "AVOID", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent, purely non-sedating second-generation antihistamine. The active metabolite of terfenadine. Highly effective but has a unique interaction with fruit juices.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **180 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be taken with water. Apple, orange, or grapefruit juice completely blocks its absorption.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Fexofenadine is the truly non-sedating antihistamine of choice when alertness is critical, but must not be taken with fruit juice as it significantly reduces absorption.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "LOW — Headache, dizziness. Completely devoid of sedative effects.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Nausea.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Allergic Rhinitis", + "val": "**PO** 120 mg **OD**.", + "tags": [] + }, + { + "key": "Urticaria", + "val": "**PO** 180 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Telfast", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (60 mg, 120 mg, 180 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S2).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Seasonal allergic rhinitis, chronic idiopathic urticaria.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Excellent non-sedating alternative for severe hives (180 mg dose is highly potent).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Renal Impairment", + "val": "CAUTION — Reduce dose in severe renal impairment (cleared slightly by kidneys).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Fexofenadine renal impairment row should prompt dose review rather than automatic contraindication." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Fexofenadine pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Organic Anion Transporting Polypeptides (OATP) in the gut absorb Fexofenadine. Fruit juices (orange, apple, grapefruit) profoundly inhibit OATP, blocking absorption by up to 70%. Drug will fail.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "MODERATE — Antacids (Aluminium/Magnesium) bind the drug in the gut. Separate by 2 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Ensure patient education regarding co-administration with water only.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Breakfast Failure", + "val": "Many patients take their morning medications with a glass of orange juice. Fexofenadine will not work if they do this. Counsel strictly to take with water.", + "tags": [] + }, + { + "key": "The Urticaria Dose", + "val": "If treating hives/urticaria, you must use the 180 mg dose. The 120 mg dose is indicated strictly for hayfever/rhinitis.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selective peripheral H1 receptor antagonist. Zero CNS penetration.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1 hour.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "14 hours. Excreted almost entirely unchanged in feces/bile.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: TELFAST/fexofenadine Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "H1 Antihistamine (2nd Gen) — Potent, purely non-sedating second-generation antihistamine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (60 mg, 120 mg, 180 mg). (Telfast)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 120 mg **OD**. Max **180 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Allergic Rhinitis: **PO** 120 mg **OD**. Urticaria: **PO** 180 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Fexofenadine is the truly non-sedating antihistamine of choice when alertness is critical, but must not be taken with fruit juice as it significantly reduces absorption." + }, + { + "label": "Avoid / Cautions", + "value": "**Pregnancy** Category B2." + }, + { + "label": "Key Risks", + "value": "Neurological: Headache, dizziness. Completely devoid of sedative effects. Gastrointestinal: Nausea." + }, + { + "label": "Key Interactions", + "value": "Organic Anion Transporting Polypeptides (OATP) in the gut absorb Fexofenadine. Fruit juices (orange, apple, grapefruit) profoundly inhibit OATP, blocking absorption by up to 70%. Drug will fail. Antacids (Aluminium/Magnesium) bind the drug in the gut. Separate by 2 hours." + }, + { + "label": "Monitoring", + "value": "Ensure patient education regarding co-administration with water only. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Many patients take their morning medications with a glass of orange juice. Fexofenadine will not work if they do this. Counsel strictly to take with water." + } + ] + }, + { + "slug": "loratadine", + "name": "Loratadine", + "class": "Allergy", + "subclass": "H1 Antihistamine (2nd Gen)", + "category": "Allergy & Anaphylaxis", + "accent": "#e11d48", + "tag": "ANTIHISTAMINE", + "schedule": "S2", + "stats": [ + { + "label": "Dose", + "value": "10 mg OD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "8-11 h", + "cls": "", + "flag": "" + }, + { + "label": "Sedation", + "value": "NONE", + "cls": "good", + "flag": "" + }, + { + "label": "Hepatic", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "True non-sedating second-generation antihistamine. Does not cross the blood-brain barrier. Excellent for daytime use.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The safest oral antihistamine for use in pregnancy.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Loratadine is the least sedating second-generation antihistamine ideal for daytime allergy relief, but is less potent than cetirizine and may be insufficient for severe urticaria.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "LOW — Headache. True sedation is at placebo levels.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Dry mouth, fatigue.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Allergic Rhinitis / Urticaria", + "val": "**PO** 10 mg **OD**.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "MANDATORY — Reduce dose to 10 mg on alternate days in severe **Hepatic** impairment.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Claratyne, Lorano", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg), Oral liquid (1 mg/mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S2).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Allergic rhinitis, chronic urticaria.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line daytime antihistamine for workers/drivers who require zero sedation.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CAUTION — Liver disease requires pharmacist/doctor review; some sources use alternate-day dosing in severe hepatic impairment. This is not an absolute contraindication.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "hepatic": ["moderate", "severe"] + }, + "note": "Loratadine needs dose/review caution in significant hepatic impairment rather than an automatic contraindication." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — Discuss risks and benefits before use in pregnancy or breastfeeding; do not present as an automatic contraindication or as unrestricted SAFE use.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "Loratadine pregnancy/breastfeeding use should prompt risk-benefit discussion." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Metabolised by CYP3A4 and CYP2D6, but interaction potential is clinically insignificant at standard doses.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Assess symptom relief and drowsiness. Stop loratadine at least 48 hours before skin allergy testing because antihistamines can interfere with test results.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Slow Starter", + "val": "Loratadine takes a few hours to peak. If a patient is having an acute, itchy urticarial flare right now, give Cetirizine instead.", + "tags": [] + }, + { + "key": "Pregnancy Choice", + "val": "If a pregnant woman has severe hayfever or hives, Loratadine has the largest, safest body of evidence for use.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selective peripheral H1 receptor antagonist. Does not penetrate the CNS.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-3 hours (Slower onset than Cetirizine).", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "8-11 hours (Active metabolite desloratadine has a half-life of 27 hours).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: CLARATYNE/loratadine Australian CMI and PBS source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "H1 Antihistamine (2nd Gen) — True non-sedating second-generation antihistamine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg), Oral liquid (1 mg/mL). (Claratyne, Lorano)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10 mg **OD**. Max **10 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Allergic Rhinitis / Urticaria: **PO** 10 mg **OD**. Hepatic Impairment: Reduce dose to 10 mg on alternate days in severe **Hepatic** impairment." + }, + { + "label": "Best Uses", + "value": "Loratadine is the least sedating second-generation antihistamine ideal for daytime allergy relief, but is less potent than cetirizine and may be insufficient for severe urticaria." + }, + { + "label": "Avoid / Cautions", + "value": "Liver disease requires pharmacist/doctor review and possible dose reduction. Discuss risks and benefits before use in pregnancy or breastfeeding; stop at least 48 hours before skin allergy testing." + }, + { + "label": "Key Risks", + "value": "Neurological: Headache. True sedation is at placebo levels. Gastrointestinal: Dry mouth, fatigue." + }, + { + "label": "Key Interactions", + "value": "Metabolised by CYP3A4 and CYP2D6, but interaction potential is clinically insignificant at standard doses." + }, + { + "label": "Monitoring", + "value": "Assess for symptom relief. If onset is too slow, switch to Cetirizine. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Loratadine takes a few hours to peak. If a patient is having an acute, itchy urticarial flare right now, give Cetirizine instead." + } + ] + }, + { + "slug": "promethazine", + "name": "Promethazine", + "class": "Sedative", + "subclass": "Phenothiazine Antihistamine", + "category": "Allergy & Anaphylaxis", + "accent": "#e11d48", + "tag": "ANTIHISTAMINE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "75 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "16–19 h", + "cls": "", + "flag": "" + }, + { + "label": "Anticholinergic", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "IV Route", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly sedating, first-generation antihistamine with phenothiazine neuroleptic properties. Used for extreme itching, severe nausea, and insomnia.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **75 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "IV administration carries a severe 'black box' risk of tissue necrosis and gangrene. Prefer deep IM or PO.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Promethazine is a potent first-generation sedating antihistamine useful for nausea and allergic reactions, but causes profound sedation and has significant anticholinergic burden especially in the elderly.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Profound sedation, hangover, confusion, delirium (especially in the elderly). Extrapyramidal side effects (EPSE) due to D2 blockade.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe dry mouth, constipation, urinary retention (Anticholinergic toxidrome).", + "tags": [] + }, + { + "key": "Tissue", + "val": "CRITICAL — Perivascular extravasation of IV Promethazine causes severe tissue necrosis and amputations.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Allergic Reactions", + "val": "**PO** 25 mg **NOCTE**. OR **IM** 25-50 mg STAT.", + "tags": [] + }, + { + "key": "Antiemetic / Motion Sickness", + "val": "**PO** 25 mg **PRN** (TDS max).", + "tags": [] + }, + { + "key": "Insomnia (Short-term)", + "val": "**PO** 25-50 mg **NOCTE**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Phenergan", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg, 25 mg). Oral liquid.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (50 mg/2 mL) for deep **IM** use. **IV** highly discouraged.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S3 PO). Prescription (S4 Ampoules).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe allergic reactions, severe nausea/vomiting, short-term insomnia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Used when the sedating side effect is specifically desired (e.g., severe nocturnal itching preventing sleep).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Children < 2 years (Risk of fatal respiratory depression).", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 2 + } + }, + "note": "Promethazine is contraindicated in children under 2 years because of fatal respiratory depression risk." + } + }, + { + "key": "Elderly / Frail", + "val": "CRITICAL — Extreme risk of anticholinergic delirium and falls. Avoid if possible.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Promethazine pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive CNS depression with opioids, benzos, and alcohol. Additive anticholinergic toxidrome with TCAs/antipsychotics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor respiratory rate if combined with opioids. Assess elderly for urinary retention and confusion.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The IV Black Box", + "val": "Due to its pH, IV Promethazine causes devastating chemical burns if it leaks out of the vein, often resulting in finger/arm amputations. If you must use it parenterally, give it deep **IM** in a large muscle mass.", + "tags": [] + }, + { + "key": "The Delirium Trap", + "val": "If an elderly patient is restless/agitated at night, DO NOT give Promethazine to 'help them sleep'. The anticholinergic payload will push them into frank hyperactive delirium.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Strongly blocks central and peripheral H1 receptors. Also possesses significant anticholinergic, anti-serotonergic, and mild dopamine (D2) blocking properties.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 20 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h (but sedation hangover lasts 12+ h).", + "tags": [] + }, + { + "key": "Half-life", + "val": "16-19 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: PHENERGAN/promethazine Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Phenothiazine Antihistamine — Highly sedating, first-generation antihistamine with phenothiazine neuroleptic properties." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg, 25 mg). Oral liquid. (Phenergan)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 25 mg **NOCTE**. OR **IM** 25-50 mg STAT. Max **75 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Severe Allergic Reactions: **PO** 25 mg **NOCTE**. OR **IM** 25-50 mg STAT. Antiemetic / Motion Sickness: **PO** 25 mg **PRN** (TDS max). Insomnia (Short-term): **PO** 25-50 mg **NOCTE**." + }, + { + "label": "Best Uses", + "value": "Promethazine is a potent first-generation sedating antihistamine useful for nausea and allergic reactions, but causes profound sedation and has significant anticholinergic burden especially in the elderly." + }, + { + "label": "Avoid / Cautions", + "value": "Children < 2 years (Risk of fatal respiratory depression). **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Profound sedation, hangover, confusion, delirium (especially in the elderly). Extrapyramidal side effects (EPSE) due to D2 blockade. Gastrointestinal: Severe dry mouth, constipation, urinary retention (Anticholinergic toxidrome). Tissue: Perivascular extravasation of IV Promethazine causes severe tissue necrosis and amputations." + }, + { + "label": "Key Interactions", + "value": "Additive CNS depression with opioids, benzos, and alcohol. Additive anticholinergic toxidrome with TCAs/antipsychotics." + }, + { + "label": "Monitoring", + "value": "Monitor respiratory rate if combined with opioids. Assess elderly for urinary retention and confusion. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Due to its pH, IV Promethazine causes devastating chemical burns if it leaks out of the vein, often resulting in finger/arm amputations. If you must use it parenterally, give it deep **IM** in a large muscle mass." + } + ] + }, + { + "slug": "buprenorphine-patch", + "name": "Buprenorphine patch", + "class": "Analgesia", + "subclass": "Partial Opioid Agonist", + "category": "Analgesia - Opioids", + "accent": "#be123c", + "tag": "OPIOID", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "40 mcg/hr", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Duration", + "value": "7 DAYS", + "cls": "good", + "flag": "" + }, + { + "label": "Heat Tox", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Safe", + "value": "YES", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Transdermal partial mu-opioid agonist. Provides a highly stable, 7-day continuous release of analgesia. Exceptional safety profile regarding respiratory depression and renal failure.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **40 mcg/hour** patch (2x 20mcg patches).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Heat drastically accelerates absorption. A hot bath or heat pack over the patch can dump a fatal dose into the blood.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Buprenorphine patch is a transdermal partial opioid agonist for chronic pain with ceiling effect on respiratory depression, but takes 12-24 hours to reach steady state and complicates acute pain management.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea, constipation (significantly less than full agonists like Oxycodone).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "HIGH — Severe erythema, pruritus, or blistering at the patch site.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Mild QTc prolongation at max doses (rarely clinically relevant).", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Chronic / Osteoarthritis Pain", + "val": "**Topical** Apply one 5 mcg/hr patch. Change exactly every 7 DAYS. Rotate sites.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "SAFE — No dose adjustment required in severe CKD or dialysis.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Norspan", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Transdermal Patches (5, 10, 15, 20 mcg/hour).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8). Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Moderate to severe chronic pain unresponsive to non-opioids.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Superb first-line baseline opioid for frail elderly patients with chronic pain, due to the 'ceiling effect' on breathing and 7-day convenience.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Acute pain, post-operative pain, opioid-naive patients needing immediate relief.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Buprenorphine patch pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Buprenorphine's extreme receptor affinity means it can physically block full agonists (like Oxycodone) from working if breakthrough pain occurs. However, at the low doses in Norspan patches (5-20 mcg/hr), this blockade is minimal and breakthrough PRN opioids usually still work fine.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Inspect the patch site. Write the date applied on the patch with a Sharpie.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Heat Trap", + "val": "Counsel the patient strictly: No hot water bottles, electric blankets, or saunas over the patch. The heat dilates skin capillaries, melting the drug reservoir directly into the blood and causing massive overdose.", + "tags": [] + }, + { + "key": "The Washout Lag", + "val": "If the patient suffers toxicity, taking the patch off doesn't fix the problem instantly. A depot of the drug exists in the subcutaneous fat that will keep absorbing into the blood for another 24 hours.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "High-affinity, partial agonist at the mu-opioid receptor. Strongly blocks pain pathways, but its partial agonism means respiratory depression maxes out (hits a ceiling) before it becomes fatal in adults.", + "tags": [] + }, + { + "key": "Onset", + "val": "**Topical** 12-24 hours to reach steady state. (Not for acute pain).", + "tags": [] + }, + { + "key": "Duration", + "val": "7 Days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "24-42 hours (Drug depot in the skin continues absorbing even after patch removal). Hepatically metabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - NORSPAN ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Partial Opioid Agonist — Transdermal partial mu-opioid agonist." + }, + { + "label": "Route / Formulation", + "value": "Transdermal Patches (5, 10, 15, 20 mcg/hour). (Norspan)" + }, + { + "label": "Usual Dose & Max", + "value": "**Topical** Apply one 5 mcg/hr patch. Change exactly every 7 DAYS. Rotate sites. Max **40 mcg/hour** patch (2x 20mcg patches)." + }, + { + "label": "Key Indication Doses", + "value": "Chronic / Osteoarthritis Pain: **Topical** Apply one 5 mcg/hr patch. Change exactly every 7 DAYS. Rotate sites. Renal Impairment: No dose adjustment required in severe CKD or dialysis." + }, + { + "label": "Best Uses", + "value": "Buprenorphine patch is a transdermal partial opioid agonist for chronic pain with ceiling effect on respiratory depression, but takes 12-24 hours to reach steady state and complicates acute pain management." + }, + { + "label": "Avoid / Cautions", + "value": "Acute pain, post-operative pain, opioid-naive patients needing immediate relief. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea, constipation (significantly less than full agonists like Oxycodone). Dermatological: Severe erythema, pruritus, or blistering at the patch site. Cardiovascular: Mild QTc prolongation at max doses (rarely clinically relevant)." + }, + { + "label": "Key Interactions", + "value": "Buprenorphine's extreme receptor affinity means it can physically block full agonists (like Oxycodone) from working if breakthrough pain occurs. However, at the low doses in Norspan patches (5-20 mcg/hr), this blockade is minimal and breakthrough PRN opioids usually still work fine." + }, + { + "label": "Monitoring", + "value": "Inspect the patch site. Write the date applied on the patch with a Sharpie. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Counsel the patient strictly: No hot water bottles, electric blankets, or saunas over the patch. The heat dilates skin capillaries, melting the drug reservoir directly into the blood and causing massive overdose." + } + ] + }, + { + "slug": "codeine", + "name": "Codeine", + "class": "Analgesia", + "subclass": "Weak Opioid", + "category": "Analgesia - Opioids", + "accent": "#be123c", + "tag": "OPIOID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "240 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3 h", + "cls": "", + "flag": "" + }, + { + "label": "Constipation", + "value": "SEVERE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "CYP2D6 Prodrug", + "value": "VARIABLE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "A weak opioid prodrug. Relies entirely on the liver to convert it into morphine to provide pain relief. Highly unpredictable efficacy across the population due to genetics.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **240 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Causes profound constipation. Up to 10% of Caucasians gain zero pain relief because they lack the enzyme to convert it to morphine.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Codeine is a weak opioid prodrug for mild-moderate pain, but has highly variable efficacy due to CYP2D6 polymorphisms (poor to ultra-rapid metabolisers) and is contraindicated in children under 12.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Severe, refractory constipation (Codeine is highly constipating even at low doses).", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Respiratory depression (especially in 'ultra-rapid metabolizers' who convert massive amounts to morphine).", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Sedation, dizziness, dependence.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Mild to Moderate Pain", + "val": "**PO** 30-60 mg q4-6h PRN. Max 240 mg/day.", + "tags": [] + }, + { + "key": "Dry Cough (Off-label)", + "val": "**PO** 15-30 mg **TDS** or **QID**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce dose and frequency if **eGFR** < 30 (Active morphine metabolites accumulate).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Panadeine Forte (combo), Panadeine (combo), Actacode", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (30 mg). Usually combined with Paracetamol (e.g., 500mg/30mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Prescription Only (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Mild to moderate pain, severe dry cough, short-term diarrhea management.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Step 2 on the WHO analgesic ladder. Increasingly superseded by safer agents due to erratic metabolism.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Children < 12 years, breastfeeding, and acute respiratory depression; risk includes fatal respiratory depression/morphine toxicity from CYP2D6 ultra-rapid metabolism.", + "tags": [], + "patient": { + "factors": ["lactation", "paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 12 + } + }, + "note": "Codeine is contraindicated in children younger than 12 years and during breastfeeding because of potentially fatal opioid toxicity." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category A; avoid third trimester/labour and contraindicated with impending childbirth or risk of premature birth because neonatal respiratory depression/withdrawal may occur.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Codeine pregnancy row is a source-backed late-pregnancy/labour caution rather than a blanket pregnancy contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — **CYP2D6** Inhibitors (Fluoxetine, Paroxetine, Bupropion). These completely block the liver from converting Codeine to Morphine. The patient will get zero pain relief.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive sedation with other CNS depressants.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Always prescribe a stimulant laxative (e.g., Senna) alongside regular codeine. Monitor respiratory rate in opioid-naive patients.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Genetic Lottery", + "val": "Codeine is useless in 'poor metabolizers' (~10% of Caucasians) because they lack CYP2D6. Conversely, 'ultra-rapid metabolizers' (~2% of Caucasians, up to 30% of Middle Eastern/African populations) convert it so fast they can suffer a fatal morphine overdose from a standard dose.", + "tags": [] + }, + { + "key": "The Paracetamol Trap", + "val": "When increasing the dose of 'Panadeine Forte', you must calculate the total paracetamol load to ensure you don't exceed 4g/day and cause fatal hepatic necrosis.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug. Has zero affinity for mu-opioid receptors itself. It must be O-demethylated in the liver into Morphine, which then binds to mu-receptors in the CNS.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3 hours. Converted by CYP2D6 into morphine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - APX-PARACETAMOL/CODEINE ARTG/PI and PBS item checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Weak Opioid — A weak opioid prodrug." + }, + { + "label": "Route / Formulation", + "value": "Tablets (30 mg). Usually combined with Paracetamol (e.g., 500mg/30mg). (Panadeine Forte (combo), Panadeine (combo), Actacode)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 30-60 mg q4-6h PRN. Max 240 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Mild to Moderate Pain: **PO** 30-60 mg q4-6h PRN. Max 240 mg/day. Dry Cough (Off-label): **PO** 15-30 mg **TDS** or **QID**. Renal Impairment: Reduce dose and frequency if **eGFR** < 30 (Active morphine metabolites accumulate)." + }, + { + "label": "Best Uses", + "value": "Codeine is a weak opioid prodrug for mild-moderate pain, but has highly variable efficacy due to CYP2D6 polymorphisms (poor to ultra-rapid metabolisers) and is contraindicated in children under 12." + }, + { + "label": "Avoid / Cautions", + "value": "Children < 12 years (Risk of fatal respiratory depression), breastfeeding mothers (fatal to infant if mother is a rapid metabolizer), acute respiratory depression. **Pregnancy** Category A, but avoid near term due to neonatal withdrawal." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe, refractory constipation (Codeine is highly constipating even at low doses). Respiratory: Respiratory depression (especially in 'ultra-rapid metabolizers' who convert massive amounts to morphine). Neurological: Sedation, dizziness, dependence." + }, + { + "label": "Key Interactions", + "value": "**CYP2D6** Inhibitors (Fluoxetine, Paroxetine, Bupropion). These completely block the liver from converting Codeine to Morphine. The patient will get zero pain relief. Additive sedation with other CNS depressants." + }, + { + "label": "Monitoring", + "value": "Always prescribe a stimulant laxative (e.g., Senna) alongside regular codeine. Monitor respiratory rate in opioid-naive patients." + }, + { + "label": "Clinical Pearl", + "value": "Codeine is useless in 'poor metabolizers' (~10% of Caucasians) because they lack CYP2D6. Conversely, 'ultra-rapid metabolizers' (~2% of Caucasians, up to 30% of Middle Eastern/African populations) convert it so fast they can suffer a fatal morphine overdose from a standard dose." + } + ] + }, + { + "slug": "fentanyl", + "name": "Fentanyl", + "class": "Analgesia", + "subclass": "Strong Opioid", + "category": "Analgesia - Opioids", + "accent": "#be123c", + "tag": "OPIOID", + "schedule": "S8", + "stats": [ + { + "label": "Potency", + "value": "100x MORPHINE", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "Minutes (IV)", + "cls": "warn", + "flag": "" + }, + { + "label": "Heat Tox", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Safe", + "value": "YES", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Synthetic, ultra-potent, ultra-lipophilic pure mu-opioid agonist. 100 times stronger than Morphine. Used IV for instant procedural analgesia or via transdermal patch for severe chronic/cancer pain.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated to effect.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Transdermal patches must NEVER be used in opioid-naive patients. They are strictly for patients already tolerant to high-dose daily opioids.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Fentanyl is the most potent synthetic opioid for severe pain and anaesthesia, but has an extremely narrow margin between therapeutic and lethal doses and is the leading cause of opioid overdose deaths.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory", + "val": "CRITICAL — Sudden, profound apnoea (especially if pushed rapidly IV).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "SAFE — Very stable. Does NOT release histamine (unlike morphine), so it maintains blood pressure perfectly in trauma/shock.", + "tags": [] + }, + { + "key": "Neuromuscular", + "val": "HIGH — Chest Wall Rigidity ('Wooden Chest Syndrome'). If pushed IV too fast, the diaphragm paralyzes, preventing ventilation.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Procedural / Acute Severe Pain", + "val": "**IV** 10-50 mcg (micrograms!) STAT. Titrate every 5 mins.", + "tags": [] + }, + { + "key": "Chronic / Cancer Pain", + "val": "**Topical** Patch applied every 72 HOURS. Start at 12 mcg/hr. Rotate sites.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "SAFE — No active metabolites. The safest IV opioid (alongside Hydromorphone) for severe renal failure.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Durogesic (Patch), Sublimaze (IV)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (100 mcg/2 mL or 500 mcg/10 mL) for **IV** use. Lozenges/Lollipops (Actiq).", + "tags": [] + }, + { + "key": "Topical", + "val": "Transdermal Patches (12, 25, 50, 75, 100 mcg/hour).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8). Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Intra-operative analgesia, severe trauma, palliative cancer pain, chronic intractable pain.", + "tags": ["TGA", "PBS"] + }, + { + "key": "Clinical Place", + "val": "The gold standard in ICU/Anaesthetics due to instant onset/offset and cardiovascular stability.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Patch use in opioid-naive patients or for acute/post-op pain (Fatal overdose risk).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Fentanyl pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP3A4** inhibitors (Clarithromycin, Ketoconazole) block hepatic clearance, spiking blood levels and risking fatal apnoea.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Benzodiazepines (Synergistic respiratory arrest).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — For patches: No heat packs or hot baths. Heat massively accelerates absorption, causing lethal overdose. Ensure old patch is removed before placing a new one.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Continuous **SpO2**, **RR**, and **BP** when giving IV.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Patch Lag", + "val": "A fentanyl patch takes 12-24 hours to reach therapeutic blood levels. Do NOT place a patch on a patient in agony and expect it to work today. You must bridge them with regular IV/PO opioids until the patch kicks in tomorrow.", + "tags": [] + }, + { + "key": "Micrograms!", + "val": "Fentanyl is dosed in MICROGRAMS. A standard starting IV dose is 25-50 mcg. Giving 1 mg (a standard morphine dose) of IV Fentanyl will kill the patient before you finish pushing the syringe.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Pure, highly potent mu-opioid agonist. Massive lipid solubility allows it to crash through the blood-brain barrier instantly.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 1-2 mins. **Topical** 12-24 hours to steady state.", + "tags": [] + }, + { + "key": "Duration", + "val": "**IV** 30-60 mins. **Topical** 72 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "IV is minutes (redistributes into fat). Patch has a 17-hour half-life *after* removal due to skin depot.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DUROGESIC ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Strong Opioid — Synthetic, ultra-potent, ultra-lipophilic pure mu-opioid agonist." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (100 mcg/2 mL or 500 mcg/10 mL) for **IV** use. Lozenges/Lollipops (Actiq). (Durogesic (Patch), Sublimaze (IV))" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 10-50 mcg (micrograms!) STAT. Titrate every 5 mins. Titrated to effect." + }, + { + "label": "Key Indication Doses", + "value": "Procedural / Acute Severe Pain: **IV** 10-50 mcg (micrograms!) STAT. Titrate every 5 mins. Chronic / Cancer Pain: **Topical** Patch applied every 72 HOURS. Start at 12 mcg/hr. Rotate sites. Renal Impairment: No active metabolites. The safest IV opioid (alongside Hydromorphone) for severe renal failure." + }, + { + "label": "Best Uses", + "value": "Fentanyl is the most potent synthetic opioid for severe pain and anaesthesia, but has an extremely narrow margin between therapeutic and lethal doses and is the leading cause of opioid overdose deaths." + }, + { + "label": "Avoid / Cautions", + "value": "Patch use in opioid-naive patients or for acute/post-op pain (Fatal overdose risk). **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Respiratory: Sudden, profound apnoea (especially if pushed rapidly IV). Cardiovascular: Very stable. Does NOT release histamine (unlike morphine), so it maintains blood pressure perfectly in trauma/shock. Neuromuscular: Chest Wall Rigidity ('Wooden Chest Syndrome'). If pushed IV too fast, the diaphragm paralyzes, preventing ventilation." + }, + { + "label": "Key Interactions", + "value": "**CYP3A4** inhibitors (Clarithromycin, Ketoconazole) block hepatic clearance, spiking blood levels and risking fatal apnoea. Benzodiazepines (Synergistic respiratory arrest)." + }, + { + "label": "Monitoring", + "value": "For patches: No heat packs or hot baths. Heat massively accelerates absorption, causing lethal overdose. Ensure old patch is removed before placing a new one. Continuous **SpO2**, **RR**, and **BP** when giving IV." + }, + { + "label": "Clinical Pearl", + "value": "A fentanyl patch takes 12-24 hours to reach therapeutic blood levels. Do NOT place a patch on a patient in agony and expect it to work today. You must bridge them with regular IV/PO opioids until the patch kicks in tomorrow." + } + ] + }, + { + "slug": "hydromorphone-ir-iv", + "name": "Hydromorphone (IR/IV)", + "class": "Analgesia", + "subclass": "Strong Opioid", + "category": "Analgesia - Opioids", + "accent": "#be123c", + "tag": "OPIOID", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Potency", + "value": "5x MORPHINE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Safe", + "value": "PREFERRED", + "cls": "good", + "flag": "" + }, + { + "label": "Half-life", + "value": "2-3 h", + "cls": "", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent, pure mu-opioid agonist. Approximately 5 to 7 times stronger than Morphine. The absolute opioid of choice for patients with renal failure.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated to effect.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Dosing errors are fatal. 1mg of Hydromorphone equals 5-7mg of Morphine. Do not confuse the ampoules.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Hydromorphone (IR/IV) is a potent opioid 5-8x stronger than morphine preferred in renal impairment, but its high potency increases the risk of dosing errors and fatal respiratory depression.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory", + "val": "CRITICAL — Profound respiratory depression. High risk of fatal overdose due to staff confusing it with morphine dosing.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Sedation, euphoria, extreme dependence.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Constipation.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Severe Pain (Opioid Naive)", + "val": "**PO** 1-2 mg q4-6h PRN. OR **IV** 0.2 - 0.5 mg STAT.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "SAFE — Does not produce toxic active metabolites. Safe to use in severe CKD and dialysis, though start low as base clearance is mildly delayed.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dilaudid, Jurnista (SR)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (2 mg, 4 mg, 8 mg). Oral liquid (1 mg/mL).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (2 mg/1 mL or 10 mg/1 mL high potency) for **IV** / **SC**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe acute and chronic pain.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The go-to IV opioid for patients with an eGFR < 30. Also used heavily in palliative care for SC syringe drivers due to high solubility (small volume required).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe respiratory depression, asthma attack.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Hydromorphone (IR/IV) pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Benzodiazepines, CNS depressants.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Strict monitoring of **SpO2**, **RR**, and Sedation Score.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Double-check the ampoule concentration. The 'HP' (High Potency) ampoule is 10mg/mL. Giving 1mL of this to a naive patient is equivalent to 50-70mg of IV Morphine and will kill them instantly.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Renal Savior", + "val": "If an elderly patient with a fractured NOF has an eGFR of 15, Morphine will give them seizures, and Oxycodone will accumulate. Hydromorphone is clean and safe, making it the definitive choice in nephrology/geriatrics.", + "tags": [] + }, + { + "key": "No Itch", + "val": "If a patient gets terrible hives or itching from IV Morphine, switch them to Hydromorphone. It triggers virtually zero histamine release.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent mu-opioid receptor agonist. Lacks the severe histamine-releasing properties of morphine (less itching and hypotension).", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 5 mins. **PO** 30 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "3-5 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours. Metabolised in the liver to Hydromorphone-3-glucuronide (inactive, no neurotoxicity!).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - HYDROMORPHONE JUNO-XHP ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Strong Opioid — Highly potent, pure mu-opioid agonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (2 mg, 4 mg, 8 mg). Oral liquid (1 mg/mL). (Dilaudid, Jurnista (SR))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1-2 mg q4-6h PRN. OR **IV** 0.2 - 0.5 mg STAT. Titrated to effect." + }, + { + "label": "Key Indication Doses", + "value": "Acute Severe Pain (Opioid Naive): **PO** 1-2 mg q4-6h PRN. OR **IV** 0.2 - 0.5 mg STAT. Renal Impairment: Does not produce toxic active metabolites. Safe to use in severe CKD and dialysis, though start low as base clearance is mildly delayed." + }, + { + "label": "Best Uses", + "value": "Hydromorphone (IR/IV) is a potent opioid 5-8x stronger than morphine preferred in renal impairment, but its high potency increases the risk of dosing errors and fatal respiratory depression." + }, + { + "label": "Avoid / Cautions", + "value": "Severe respiratory depression, asthma attack. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Respiratory: Profound respiratory depression. High risk of fatal overdose due to staff confusing it with morphine dosing. Neurological: Sedation, euphoria, extreme dependence. Gastrointestinal: Constipation." + }, + { + "label": "Key Interactions", + "value": "Benzodiazepines, CNS depressants." + }, + { + "label": "Monitoring", + "value": "Strict monitoring of **SpO2**, **RR**, and Sedation Score. Double-check the ampoule concentration. The 'HP' (High Potency) ampoule is 10mg/mL. Giving 1mL of this to a naive patient is equivalent to 50-70mg of IV Morphine and will kill them instantly." + }, + { + "label": "Clinical Pearl", + "value": "If an elderly patient with a fractured NOF has an eGFR of 15, Morphine will give them seizures, and Oxycodone will accumulate. Hydromorphone is clean and safe, making it the definitive choice in nephrology/geriatrics." + } + ] + }, + { + "slug": "morphine-ir-iv", + "name": "Morphine (IR/IV)", + "class": "Analgesia", + "subclass": "Strong Opioid", + "category": "Analgesia - Opioids", + "accent": "#be123c", + "tag": "OPIOID", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-4 h", + "cls": "", + "flag": "" + }, + { + "label": "Renal Tox", + "value": "ACTIVE METABOLITES", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Histamine", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The classical gold-standard mu-opioid agonist. Highly effective for severe pain and dyspnea (APO/palliative). ", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated to effect.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Morphine produces highly active toxic metabolites that rely 100% on the kidneys for clearance. Lethal if used in severe renal failure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Morphine (IR/IV) is the gold-standard strong opioid for severe acute pain and palliative care, but causes respiratory depression, histamine release, and accumulates active metabolites in renal failure.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory", + "val": "CRITICAL — Respiratory depression, apnoea.", + "tags": [] + }, + { + "key": "Renal/Neuro", + "val": "CRITICAL — M3G accumulation in CKD causes severe hyperalgesia, massive myoclonic jerks, and intractable seizures.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Hypotension (due to massive histamine release).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Constipation, nausea, biliary spasm (Sphincter of Oddi spasm).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Severe Pain", + "val": "**IV** 2-5 mg bolus, repeat every 5-10 mins PRN until pain controlled. OR **PO** 5-10 mg (IR liquid/tablet) q4h PRN.", + "tags": [] + }, + { + "key": "Acute Pulmonary Oedema", + "val": "**IV** 2.5-5 mg STAT (Reduces preload via histamine release and blunts air hunger).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — If **eGFR** < 30, avoid Morphine entirely. Switch to Hydromorphone or Fentanyl to prevent neurotoxic metabolite accumulation.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Sevredol, Ordine (liquid)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets IR (10, 20 mg). Oral liquid (2 mg/mL, 10 mg/mL).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (10 mg/1 mL) for **IV** / **IM** / **SC**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe acute/chronic pain, myocardial infarction, acute pulmonary oedema, palliative dyspnea.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line IV opioid on the ward. Unmatched for reducing preload in cardiac emergencies.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal impairment (eGFR < 30), severe asthma, paralytic ileus.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Morphine (IR/IV) pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Benzodiazepines, Gabapentinoids (fatal respiratory arrest).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Antihypertensives (Morphine's histamine release guarantees a massive BP drop if given fast IV to a patient on BP meds).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **SpO2**, **RR**, **BP**, and Sedation Score. If pushing IV, push slowly over 2-3 mins to minimize histamine/hypotension.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — Check **eGFR** before charting regular morphine.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Renal Seizure", + "val": "If an elderly patient with bad kidneys is given regular morphine, the M3G metabolite builds up in the brain. They will start violently twitching (myoclonus) and their pain will paradoxically get worse. Do not give them more morphine! Switch to Fentanyl/Hydromorphone and flush with fluids.", + "tags": [] + }, + { + "key": "The Itch", + "val": "Morphine directly pops mast cells, releasing histamine. Patients will aggressively scratch their nose and chest. This is a physiological reaction, NOT an anaphylactic allergy. Treat with an antihistamine, or switch to Fentanyl (which releases zero histamine).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Pure agonist at mu and kappa opioid receptors. Also triggers direct mast-cell degranulation (histamine release) causing potent venodilation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 5-10 mins. **PO** 30 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "3-5 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-4 hours. Metabolised in liver to M3G (neurotoxic) and M6G (highly potent analgesic), both of which are strictly renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DBL MORPHINE SULFATE ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Strong Opioid — The classical gold-standard mu-opioid agonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets IR (10, 20 mg). Oral liquid (2 mg/mL, 10 mg/mL). (Sevredol, Ordine (liquid))" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 2-5 mg bolus, repeat every 5-10 mins PRN until pain controlled. OR **PO** 5-10 mg (IR liquid/tablet) q4h PRN. Titrated to effect." + }, + { + "label": "Key Indication Doses", + "value": "Acute Severe Pain: **IV** 2-5 mg bolus, repeat every 5-10 mins PRN until pain controlled. OR **PO** 5-10 mg (IR liquid/tablet) q4h PRN. Acute Pulmonary Oedema: **IV** 2.5-5 mg STAT (Reduces preload via histamine release and blunts air hunger). Renal Impairment: If **eGFR** < 30, avoid Morphine entirely. Switch to Hydromorphone or Fentanyl to prevent neurotoxic metabolite accumulation." + }, + { + "label": "Best Uses", + "value": "Morphine (IR/IV) is the gold-standard strong opioid for severe acute pain and palliative care, but causes respiratory depression, histamine release, and accumulates active metabolites in renal failure." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal impairment (eGFR < 30), severe asthma, paralytic ileus. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Respiratory: Respiratory depression, apnoea. Renal/Neuro: M3G accumulation in CKD causes severe hyperalgesia, massive myoclonic jerks, and intractable seizures. Cardiovascular: Hypotension (due to massive histamine release). Gastrointestinal: Constipation, nausea, biliary spasm (Sphincter of Oddi spasm)." + }, + { + "label": "Key Interactions", + "value": "Benzodiazepines, Gabapentinoids (fatal respiratory arrest). Antihypertensives (Morphine's histamine release guarantees a massive BP drop if given fast IV to a patient on BP meds)." + }, + { + "label": "Monitoring", + "value": "Monitor **SpO2**, **RR**, **BP**, and Sedation Score. If pushing IV, push slowly over 2-3 mins to minimize histamine/hypotension. Check **eGFR** before charting regular morphine." + }, + { + "label": "Clinical Pearl", + "value": "If an elderly patient with bad kidneys is given regular morphine, the M3G metabolite builds up in the brain. They will start violently twitching (myoclonus) and their pain will paradoxically get worse. Do not give them more morphine! Switch to Fentanyl/Hydromorphone and flush with fluids." + } + ] + }, + { + "slug": "morphine-sr-mr", + "name": "Morphine SR / MR", + "class": "Analgesia", + "subclass": "Strong Opioid", + "category": "Analgesia - Opioids", + "accent": "#be123c", + "tag": "OPIOID", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Freq", + "value": "BD Dosing", + "cls": "good", + "flag": "" + }, + { + "label": "Do Not Crush", + "value": "FATAL RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Renal Tox", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Sustained-release oral morphine. Provides 12-hour baseline analgesia for severe chronic or cancer-related pain.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated to effect.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must never be crushed. Carries the same severe renal toxicity warnings as immediate-release morphine.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Morphine SR / MR is a sustained-release formulation for chronic severe pain and palliative care, but must never be crushed and requires breakthrough IR morphine for incident pain management.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory", + "val": "CRITICAL — Apnoea if crushed or chewed.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe constipation.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Sedation, delirium, tolerance.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Chronic Pain", + "val": "Start **PO** 10-15 mg **BD** (strictly q12h). Titrate every 48 hours to effect.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Avoid if **eGFR** < 30 due to fatal accumulation of M3G/M6G metabolites. Switch to SR Hydromorphone (Jurnista) or a Fentanyl Patch.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "MS Contin, Kapanol", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Sustained-release tablets/capsules (5, 10, 15, 30, 60, 100 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8). Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe chronic pain, palliative care.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Baseline analgesia in oncology and palliative care. Less frequently used for benign chronic pain due to modern preference for Tapentadol or Buprenorphine.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Renal failure, paralytic ileus, respiratory depression.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Avoid sustained-release morphine in severe renal impairment because morphine metabolites accumulate." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Benzodiazepines (Synergistic respiratory arrest).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure intact swallowing. Monitor **RR** and sedation.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Kapanol Exception", + "val": "While MS Contin tablets can never be broken, Kapanol capsules contain micro-pellets. The capsule can be opened and the pellets sprinkled on yogurt or down a feeding tube, provided the pellets themselves are not crushed. This is brilliant for dysphagic palliative patients.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Slow-release matrix delivers continuous mu-opioid agonism.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2-3 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12 h (Kapanol matrix can last 24 h).", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-4 hours (but absorption is delayed to provide 12h effect).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - MS CONTIN ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Strong Opioid — Sustained-release oral morphine." + }, + { + "label": "Route / Formulation", + "value": "Sustained-release tablets/capsules (5, 10, 15, 30, 60, 100 mg). (MS Contin, Kapanol)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 10-15 mg **BD** (strictly q12h). Titrate every 48 hours to effect. Titrated to effect." + }, + { + "label": "Key Indication Doses", + "value": "Chronic Pain: Start **PO** 10-15 mg **BD** (strictly q12h). Titrate every 48 hours to effect. Renal Impairment: Avoid if **eGFR** < 30 due to fatal accumulation of M3G/M6G metabolites. Switch to SR Hydromorphone (Jurnista) or a Fentanyl Patch." + }, + { + "label": "Best Uses", + "value": "Morphine SR / MR is a sustained-release formulation for chronic severe pain and palliative care, but must never be crushed and requires breakthrough IR morphine for incident pain management." + }, + { + "label": "Avoid / Cautions", + "value": "Renal failure, paralytic ileus, respiratory depression." + }, + { + "label": "Key Risks", + "value": "Respiratory: Apnoea if crushed or chewed. Gastrointestinal: Severe constipation. Neurological: Sedation, delirium, tolerance." + }, + { + "label": "Key Interactions", + "value": "Benzodiazepines (Synergistic respiratory arrest)." + }, + { + "label": "Monitoring", + "value": "Ensure intact swallowing. Monitor **RR** and sedation. Check **eGFR**." + }, + { + "label": "Clinical Pearl", + "value": "While MS Contin tablets can never be broken, Kapanol capsules contain micro-pellets. The capsule can be opened and the pellets sprinkled on yogurt or down a feeding tube, provided the pellets themselves are not crushed. This is brilliant for dysphagic palliative patients." + } + ] + }, + { + "slug": "oxycodone-ir", + "name": "Oxycodone IR", + "class": "Analgesia", + "subclass": "Strong Opioid", + "category": "Analgesia - Opioids", + "accent": "#be123c", + "tag": "OPIOID", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3-5 h", + "cls": "", + "flag": "" + }, + { + "label": "Dependence", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Constipation", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent, pure mu-opioid receptor agonist. The most widely prescribed strong oral opioid on the ward. Extremely high abuse and dependence potential.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "No absolute ceiling dose. Titrated strictly to pain response and respiratory tolerance.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Has roughly 1.5 to 2 times the oral potency of oral Morphine. Massive risk of iatrogenic addiction if sent home with large discharge supplies.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Oxycodone IR is a potent Schedule 8 opioid for moderate-severe acute pain, but has high abuse potential and causes significant respiratory depression, constipation, and dependence.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory", + "val": "CRITICAL — Dose-dependent respiratory depression and fatal apnoea.", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Euphoria, rapid tolerance, severe physical/psychological dependence. HIGH — Sedation, delirium, miosis (pinpoint pupils).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe constipation (paralyzes gut peristalsis), nausea, vomiting.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Severe Pain", + "val": "**PO** 5-10 mg q4-6h PRN. Titrate to effect.", + "tags": [] + }, + { + "key": "Breakthrough Pain (for SR users)", + "val": "**PO** Give 1/6th of the total daily Sustained Release dose as an IR PRN dose q2-4h.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Start at 2.5 mg (half a 5mg tablet) q6h PRN. Highly sensitive to sedation/delirium.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce dose/increase interval if **eGFR** < 30. (Accumulates, though less toxic than morphine metabolites).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Endone, Oxynorm", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets/Capsules (5 mg, 10 mg, 20 mg). Oral liquid (1 mg/mL and 10 mg/mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8). PBS strictly limits quantities for acute pain.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Moderate to severe acute and chronic pain, post-operative pain, cancer pain.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The workhorse 'breakthrough' analgesic on surgical and medical wards. Used when pain breaks through the Paracetamol/NSAID baseline.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe respiratory depression, severe acute asthma, paralytic ileus.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C. Chronic use causes Neonatal Abstinence Syndrome (NAS).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Oxycodone IR pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Benzodiazepines, Gabapentinoids, Alcohol. Co-administration is the #1 cause of fatal opioid overdoses due to profound synergistic respiratory depression.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP3A4** inhibitors (Clarithromycin, Azoles) increase oxycodone blood levels and toxicity.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Strict monitoring of **SpO2**, **RR**, and Sedation Score (AVPU). Withhold if RR < 12 or patient is unrousable.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Must co-prescribe a stimulant laxative (Senna) from Day 1 to prevent bowel impaction.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Discharge Disaster", + "val": "Never discharge a patient with a box of 20 Endone for a simple sprain. 3 days of opioid use triggers physical tolerance; 5 days triggers withdrawal. Prescribe tiny quantities (e.g., 5-10 tablets) and instruct them to use Paracetamol/Ibuprofen first.", + "tags": [] + }, + { + "key": "The Liquid Danger", + "val": "Oxynorm liquid comes in 1 mg/mL and a highly concentrated 10 mg/mL form. A drawing error of 5mL of the concentrate yields 50mg of oxycodone—a massive, potentially fatal overdose in an opioid-naive patient. Double-check the bottle!", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Pure agonist at the mu-opioid receptor in the CNS. Inhibits ascending pain pathways and alters the brain's perception of and emotional response to pain.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 20-30 mins. Peak at 1 hour.", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-5 hours. Metabolised by CYP3A4 to weakly active oxymorphone.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ENDONE ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Strong Opioid — Highly potent, pure mu-opioid receptor agonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets/Capsules (5 mg, 10 mg, 20 mg). Oral liquid (1 mg/mL and 10 mg/mL). (Endone, Oxynorm)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5-10 mg q4-6h PRN. Titrate to effect. No absolute ceiling dose. Titrated strictly to pain response and respiratory tolerance." + }, + { + "label": "Key Indication Doses", + "value": "Acute Severe Pain: **PO** 5-10 mg q4-6h PRN. Titrate to effect. Breakthrough Pain (for SR users): **PO** Give 1/6th of the total daily Sustained Release dose as an IR PRN dose q2-4h. Elderly / Frail: Start at 2.5 mg (half a 5mg tablet) q6h PRN. Highly sensitive to sedation/delirium. Renal Impairment: Reduce dose/increase interval if **eGFR** < 30. (Accumulates, though less toxic than morphine metabolites)." + }, + { + "label": "Best Uses", + "value": "Oxycodone IR is a potent Schedule 8 opioid for moderate-severe acute pain, but has high abuse potential and causes significant respiratory depression, constipation, and dependence." + }, + { + "label": "Avoid / Cautions", + "value": "Severe respiratory depression, severe acute asthma, paralytic ileus. **Pregnancy** Category C. Chronic use causes Neonatal Abstinence Syndrome (NAS)." + }, + { + "label": "Key Risks", + "value": "Respiratory: Dose-dependent respiratory depression and fatal apnoea. Neurological: Euphoria, rapid tolerance, severe physical/psychological dependence. HIGH — Sedation, delirium, miosis (pinpoint pupils). Gastrointestinal: Severe constipation (paralyzes gut peristalsis), nausea, vomiting." + }, + { + "label": "Key Interactions", + "value": "Benzodiazepines, Gabapentinoids, Alcohol. Co-administration is the #1 cause of fatal opioid overdoses due to profound synergistic respiratory depression. **CYP3A4** inhibitors (Clarithromycin, Azoles) increase oxycodone blood levels and toxicity." + }, + { + "label": "Monitoring", + "value": "Strict monitoring of **SpO2**, **RR**, and Sedation Score (AVPU). Withhold if RR < 12 or patient is unrousable. Must co-prescribe a stimulant laxative (Senna) from Day 1 to prevent bowel impaction." + }, + { + "label": "Clinical Pearl", + "value": "Never discharge a patient with a box of 20 Endone for a simple sprain. 3 days of opioid use triggers physical tolerance; 5 days triggers withdrawal. Prescribe tiny quantities (e.g., 5-10 tablets) and instruct them to use Paracetamol/Ibuprofen first." + } + ] + }, + { + "slug": "oxycodone-sr-mr", + "name": "Oxycodone SR / MR", + "class": "Analgesia", + "subclass": "Strong Opioid", + "category": "Analgesia - Opioids", + "accent": "#be123c", + "tag": "OPIOID", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Freq", + "value": "BD Dosing", + "cls": "good", + "flag": "" + }, + { + "label": "Do Not Crush", + "value": "FATAL RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Targin", + "value": "NALOXONE COMBO", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Sustained-release pure mu-opioid agonist. Provides a flat, 12-hour baseline of pain control. Often formulated with naloxone (Targin) to prevent gut paralysis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated to effect. Must calculate Total Daily Dose of IR opioids to convert safely to SR.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never crush or chew SR tablets. Doing so destroys the release matrix, dumping 12 hours of fentanyl-strength opioid into the blood instantly, causing fatal respiratory arrest.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Oxycodone SR / MR is a sustained-release opioid for chronic severe pain requiring around-the-clock analgesia, but must never be crushed (dose-dumping risk) and carries the highest abuse potential among oral opioids.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory", + "val": "CRITICAL — Respiratory depression, especially during dose escalation or if tablets are crushed.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Constipation (Significantly lower if using Targin, but still requires monitoring).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Sedation, delirium, tolerance, hyperalgesia (worsening pain sensitivity with chronic use).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Chronic / Post-Op Pain", + "val": "**PO** 10-20 mg **BD** (q12h strictly). Titrate every 2-3 days.", + "tags": [] + }, + { + "key": "Opioid Conversion", + "val": "Calculate the 24-hour total of immediate-release (IR) Oxycodone used, divide by 2, and prescribe that amount **BD**.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Start at 5 mg **BD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "OxyContin, Targin (Oxycodone/Naloxone)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Sustained-release tablets (5, 10, 15, 20, 30, 40, 80 mg). MUST be swallowed whole.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8). Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Management of severe chronic pain, cancer pain, or severe post-op pain requiring around-the-clock analgesia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The 'Basal' pain control. Should always be paired with an IR 'Bolus' opioid for breakthrough pain.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Paralytic ileus, severe respiratory depression.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "CRITICAL — (Specific to Targin). In severe liver failure, the liver cannot destroy the oral Naloxone. The Naloxone will enter the systemic blood and reverse the pain relief, plunging the patient into acute withdrawal. Avoid Targin in cirrhosis.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Benzodiazepines (Synergistic respiratory arrest).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — CYP3A4 inhibitors (spikes levels).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **SpO2**, **RR**, and Sedation score. If the patient is difficult to rouse, withhold the next dose immediately and notify medical staff.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Ensure the patient is actually swallowing the tablet intact. Checking mouths in confused patients is critical to prevent chewing.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Targin Ceiling", + "val": "The Naloxone in Targin has a ceiling. If you prescribe more than 80/40mg or 120/60mg of Targin a day, the liver becomes overwhelmed and the Naloxone spills into the blood, triggering withdrawal. If they need massive doses, switch back to OxyContin + Senna.", + "tags": [] + }, + { + "key": "Not for PRN", + "val": "SR opioids take 2 hours to work and last 12 hours. NEVER write them up as 'PRN' for acute pain. They are strictly regular (BD) medications.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Slow-release matrix delivers continuous mu-opioid agonism. In Targin, the oral naloxone blocks opioid receptors locally in the gut to prevent constipation, but is entirely destroyed by liver first-pass metabolism, allowing the oxycodone to reach the brain unhindered.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "4.5 hours (but the matrix delays absorption to provide 12h coverage).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - OXYCONTIN/TARGIN ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Strong Opioid — Sustained-release pure mu-opioid agonist." + }, + { + "label": "Route / Formulation", + "value": "Sustained-release tablets (5, 10, 15, 20, 30, 40, 80 mg). MUST be swallowed whole. (OxyContin, Targin (Oxycodone/Naloxone))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10-20 mg **BD** (q12h strictly). Titrate every 2-3 days. Titrated to effect. Must calculate Total Daily Dose of IR opioids to convert safely to SR." + }, + { + "label": "Key Indication Doses", + "value": "Chronic / Post-Op Pain: **PO** 10-20 mg **BD** (q12h strictly). Titrate every 2-3 days. Opioid Conversion: Calculate the 24-hour total of immediate-release (IR) Oxycodone used, divide by 2, and prescribe that amount **BD**. Elderly / Frail: Start at 5 mg **BD**." + }, + { + "label": "Best Uses", + "value": "Oxycodone SR / MR is a sustained-release opioid for chronic severe pain requiring around-the-clock analgesia, but must never be crushed (dose-dumping risk) and carries the highest abuse potential among oral opioids." + }, + { + "label": "Avoid / Cautions", + "value": "Paralytic ileus, severe respiratory depression." + }, + { + "label": "Key Risks", + "value": "Respiratory: Respiratory depression, especially during dose escalation or if tablets are crushed. Gastrointestinal: Constipation (Significantly lower if using Targin, but still requires monitoring). Neurological: Sedation, delirium, tolerance, hyperalgesia (worsening pain sensitivity with chronic use)." + }, + { + "label": "Key Interactions", + "value": "Benzodiazepines (Synergistic respiratory arrest). CYP3A4 inhibitors (spikes levels)." + }, + { + "label": "Monitoring", + "value": "Monitor **SpO2**, **RR**, and Sedation score. If the patient is difficult to rouse, withhold the next dose immediately and notify medical staff. Ensure the patient is actually swallowing the tablet intact. Checking mouths in confused patients is critical to prevent chewing." + }, + { + "label": "Clinical Pearl", + "value": "The Naloxone in Targin has a ceiling. If you prescribe more than 80/40mg or 120/60mg of Targin a day, the liver becomes overwhelmed and the Naloxone spills into the blood, triggering withdrawal. If they need massive doses, switch back to OxyContin + Senna." + } + ] + }, + { + "slug": "tapentadol-sr", + "name": "Tapentadol SR", + "class": "Analgesia", + "subclass": "Opioid + NRI", + "category": "Analgesia - Opioids", + "accent": "#be123c", + "tag": "OPIOID", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "500 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5-6 h", + "cls": "", + "flag": "" + }, + { + "label": "Metabolites", + "value": "INACTIVE", + "cls": "good", + "flag": "" + }, + { + "label": "GI Side Effects", + "value": "LOWER", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Modern, dual-acting centrally acting analgesic. Combines mu-opioid agonism with Noradrenaline Reuptake Inhibition (NRI). Significantly cleaner side effect profile than Tramadol.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **500 mg/day** (Sustained Release).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Tapentadol has zero effect on serotonin, completely eliminating the Serotonin Syndrome risk seen with Tramadol. Extremely effective for neuropathic pain.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Tapentadol SR is a dual-mechanism opioid (mu-agonist + NRI) for chronic pain with less GI side effects than traditional opioids, but carries full opioid dependence risk and serotonin syndrome potential.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "LOW — Nausea, vomiting, and constipation are statistically much lower than equivalent doses of Oxycodone or Morphine.", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Dizziness, somnolence. (Lower seizure risk than tramadol).", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Respiratory depression (though theoretically slightly less than pure mu-agonists like oxycodone).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Chronic / Neuropathic Pain", + "val": "Start **PO** 50 mg **BD** (SR tablets). Titrate by 50 mg/day every 3-5 days to target pain relief. Max 500 mg/day.", + "tags": [] + }, + { + "key": "Acute Severe Pain", + "val": "**PO** 50-100 mg q4-6h PRN (IR tablets, max 700mg on day 1 only, then 600mg).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Avoid if **eGFR** < 30 (Lack of safety data, though theoretically safer than morphine).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Palexia IR, Palexia SR", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "IR Tablets (50 mg). Sustained Release Tablets (50, 100, 150, 200, 250 mg). Do not crush SR.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Highly Restricted (S8).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe chronic pain, chronic neuropathic pain (e.g., diabetic neuropathy), severe acute pain.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Step 3 on the analgesic ladder. Superb replacement for Oxycodone to vastly reduce constipation/nausea, and superior to Tramadol as it lacks seizure/serotonin risks.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent MAOI use, severe respiratory depression, paralytic ileus.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Tapentadol SR pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Tapentadol does NOT rely on CYP450 enzymes. It is immune to the drug interactions that plague Tramadol and Codeine.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive sedation with alcohol, benzos, and antipsychotics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **SpO2** and **RR** upon initiation. Assess for adequate pain relief.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Neuropathic Edge", + "val": "Because of the strong noradrenaline reuptake inhibition, Tapentadol is uniquely effective for nerve pain (sciatica, radiculopathy, diabetic neuropathy) where pure opioids like Oxycodone often fail miserably.", + "tags": [] + }, + { + "key": "The Clean Liver", + "val": "Unlike Tramadol or Codeine which are prodrugs requiring a healthy liver and specific genetics to work, Tapentadol is the active drug itself. It works reliably in 100% of the population regardless of their CYP2D6 status.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Direct mu-opioid receptor (MOR) agonist AND Noradrenaline Reuptake Inhibitor (NRI). The NRI action heavily dampens descending neuropathic pain pathways in the spinal cord.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-45 mins (IR).", + "tags": [] + }, + { + "key": "Duration", + "val": "12 h (SR formulation).", + "tags": [] + }, + { + "key": "Half-life", + "val": "5-6 hours. Undergoes Phase II glucuronidation directly. Has NO active metabolites.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - PALEXIA SR ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Opioid + NRI — Modern, dual-acting centrally acting analgesic." + }, + { + "label": "Route / Formulation", + "value": "IR Tablets (50 mg). Sustained Release Tablets (50, 100, 150, 200, 250 mg). Do not crush SR. (Palexia IR, Palexia SR)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 50 mg **BD** (SR tablets). Titrate by 50 mg/day every 3-5 days to target pain relief. Max 500 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Chronic / Neuropathic Pain: Start **PO** 50 mg **BD** (SR tablets). Titrate by 50 mg/day every 3-5 days to target pain relief. Max 500 mg/day. Acute Severe Pain: **PO** 50-100 mg q4-6h PRN (IR tablets, max 700mg on day 1 only, then 600mg). Renal Impairment: Avoid if **eGFR** < 30 (Lack of safety data, though theoretically safer than morphine)." + }, + { + "label": "Best Uses", + "value": "Tapentadol SR is a dual-mechanism opioid (mu-agonist + NRI) for chronic pain with less GI side effects than traditional opioids, but carries full opioid dependence risk and serotonin syndrome potential." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent MAOI use, severe respiratory depression, paralytic ileus. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea, vomiting, and constipation are statistically much lower than equivalent doses of Oxycodone or Morphine. Neurological: Dizziness, somnolence. (Lower seizure risk than tramadol). Respiratory: Respiratory depression (though theoretically slightly less than pure mu-agonists like oxycodone)." + }, + { + "label": "Key Interactions", + "value": "Tapentadol does NOT rely on CYP450 enzymes. It is immune to the drug interactions that plague Tramadol and Codeine. Additive sedation with alcohol, benzos, and antipsychotics." + }, + { + "label": "Monitoring", + "value": "Monitor **SpO2** and **RR** upon initiation. Assess for adequate pain relief. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Because of the strong noradrenaline reuptake inhibition, Tapentadol is uniquely effective for nerve pain (sciatica, radiculopathy, diabetic neuropathy) where pure opioids like Oxycodone often fail miserably." + } + ] + }, + { + "slug": "tramadol-ir", + "name": "Tramadol IR", + "class": "Analgesia", + "subclass": "Weak Opioid + SNRI", + "category": "Analgesia - Opioids", + "accent": "#be123c", + "tag": "OPIOID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6 h", + "cls": "", + "flag": "" + }, + { + "label": "Seizure Risk", + "value": "DOSE-DEP", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Serotonin Synd.", + "value": "RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Atypical centrally-acting analgesic. Combines weak mu-opioid agonism with Serotonin and Noradrenaline Reuptake Inhibition (SNRI). Highly effective but riddled with neurological drug interactions.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mg/day** (Max 300 mg/day in the elderly).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Massively lowers the seizure threshold and carries a severe risk of Serotonin Syndrome if mixed with antidepressants.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Tramadol IR is a dual-mechanism analgesic (weak opioid + SNRI) for moderate pain, but lowers the seizure threshold significantly and causes serotonin syndrome when combined with other serotonergic drugs.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Seizures (highly dose-dependent, occurs even in patients without epilepsy). CRITICAL — Serotonin Syndrome. HIGH — Dizziness, confusion, delirium (especially in elderly).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe nausea/vomiting (much higher than other opioids). MODERATE — Constipation (less than codeine/morphine).", + "tags": [] + }, + { + "key": "Respiratory", + "val": "LOW — Respiratory depression is significantly less common than with classical opioids.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Moderate-Severe Pain", + "val": "**PO** / **IV** / **IM** 50-100 mg q4-6h PRN. Max 400 mg/day.", + "tags": [] + }, + { + "key": "Elderly (> 75 years)", + "val": "MANDATORY — Max **300 mg/day**. Start low (25-50 mg).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Max 200 mg/day if **eGFR** < 30. Increase dosing interval to q12h.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Tramal, Zydol", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets (50 mg). Sustained Release (100, 150, 200 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (100 mg/2 mL) for **IV** / **IM** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). S4 (but tightly monitored due to abuse).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Moderate to severe acute and chronic pain.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Step 2 on the analgesic ladder. Used when patients cannot tolerate the constipation of codeine or the strength of oxycodone.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Uncontrolled epilepsy, concurrent MAOI use.", + "tags": [] + }, + { + "key": "Elderly", + "val": "HIGH — Causes severe confusion and falls. Use with extreme caution.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "caution", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Older adults have higher tramadol delirium, falls, seizure, and interaction risk; use cautiously and monitor." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Tramadol IR pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — SSRIs, SNRIs, TCAs, St John's Wort. Massive risk of lethal Serotonin Syndrome (hyperthermia, rigidity, clonus).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — CYP2D6 inhibitors (Fluoxetine, Paroxetine) block conversion to the active M1 opioid metabolite, robbing the patient of opioid pain relief while increasing the SNRI seizure/serotonin risks.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for signs of serotonin toxicity (agitation, sweating, shivering, brisk reflexes). Co-prescribe an antiemetic (Ondansetron) for the first few days.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** to guide maximum daily dose limits.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Ondansetron Antagonism", + "val": "Ondansetron is a 5-HT3 antagonist. Tramadol relies on serotonin pathways for pain relief. Giving them together not only increases serotonin syndrome risk, but actually *reduces* the pain relief of Tramadol. Consider Metoclopramide instead if not contraindicated.", + "tags": [] + }, + { + "key": "The Naloxone Failure", + "val": "If a patient overdoses on Tramadol, Naloxone will only reverse the opioid (respiratory depression) part of the overdose. It does NOTHING for the SNRI-induced seizures or serotonin syndrome.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Dual action: 1) The parent drug inhibits reuptake of serotonin and noradrenaline (pain pathway inhibition). 2) Converted by the liver into the 'O-desmethyl' active metabolite (M1), which binds the mu-opioid receptor.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "6 hours. Extensively metabolised by CYP2D6 (to active M1) and CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TRAMAL ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Weak Opioid + SNRI — Atypical centrally-acting analgesic." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets (50 mg). Sustained Release (100, 150, 200 mg). (Tramal, Zydol)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** / **IV** / **IM** 50-100 mg q4-6h PRN. Max 400 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Moderate-Severe Pain: **PO** / **IV** / **IM** 50-100 mg q4-6h PRN. Max 400 mg/day. Elderly (> 75 years): Max **300 mg/day**. Start low (25-50 mg). Renal Impairment: Max 200 mg/day if **eGFR** < 30. Increase dosing interval to q12h." + }, + { + "label": "Best Uses", + "value": "Tramadol IR is a dual-mechanism analgesic (weak opioid + SNRI) for moderate pain, but lowers the seizure threshold significantly and causes serotonin syndrome when combined with other serotonergic drugs." + }, + { + "label": "Avoid / Cautions", + "value": "Uncontrolled epilepsy, concurrent MAOI use. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Seizures (highly dose-dependent, occurs even in patients without epilepsy). CRITICAL — Serotonin Syndrome. HIGH — Dizziness, confusion, delirium (especially in elderly). Gastrointestinal: Severe nausea/vomiting (much higher than other opioids). MODERATE — Constipation (less than codeine/morphine). Respiratory: Respiratory depression is significantly less common than with classical opioids." + }, + { + "label": "Key Interactions", + "value": "SSRIs, SNRIs, TCAs, St John's Wort. Massive risk of lethal Serotonin Syndrome (hyperthermia, rigidity, clonus). CYP2D6 inhibitors (Fluoxetine, Paroxetine) block conversion to the active M1 opioid metabolite, robbing the patient of opioid pain relief while increasing the SNRI seizure/serotonin risks." + }, + { + "label": "Monitoring", + "value": "Monitor for signs of serotonin toxicity (agitation, sweating, shivering, brisk reflexes). Co-prescribe an antiemetic (Ondansetron) for the first few days. Check **eGFR** to guide maximum daily dose limits." + }, + { + "label": "Clinical Pearl", + "value": "Ondansetron is a 5-HT3 antagonist. Tramadol relies on serotonin pathways for pain relief. Giving them together not only increases serotonin syndrome risk, but actually *reduces* the pain relief of Tramadol. Consider Metoclopramide instead if not contraindicated." + } + ] + }, + { + "slug": "celecoxib", + "name": "Celecoxib", + "class": "Analgesia", + "subclass": "COX-2 Inhibitor", + "category": "Analgesia - Simple & NSAIDs", + "accent": "#be123c", + "tag": "NSAID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "11 h", + "cls": "", + "flag": "" + }, + { + "label": "GI Bleed", + "value": "LOWER RISK", + "cls": "good", + "flag": "" + }, + { + "label": "CV Risk", + "value": "MONITOR", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly selective COX-2 inhibitor ('Coxib'). Designed to provide the anti-inflammatory power of an NSAID while sparing the stomach lining from ulceration.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mg/day** (e.g., 200 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Much safer for the GI tract, but carries a higher risk of pro-thrombotic cardiovascular events (MI/Stroke) than non-selective agents like Naproxen.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Celecoxib is a selective COX-2 inhibitor with lower GI bleeding risk than traditional NSAIDs, but carries the same cardiovascular risk and is contraindicated in sulfonamide allergy.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Increased risk of myocardial infarction, stroke, heart failure, and hypertension. (Selectively blocking COX-2 drops prostacyclin—a vasodilator—while leaving COX-1 thromboxane—a clot promoter—unopposed).", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal", + "val": "HIGH — AKI, fluid retention, hyperkalemia. (COX-2 selectivity does NOT protect the kidneys. The renal risk is identical to Ibuprofen).", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "LOW — Ulcers and bleeding are significantly reduced compared to standard NSAIDs, but risk is not zero.", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Osteoarthritis / RA", + "val": "**PO** 100-200 mg **OD** or divided **BD**.", + "tags": [] + }, + { + "key": "Acute Pain / Dysmenorrhoea", + "val": "**PO** 400 mg STAT on Day 1, then 200 mg **BD**.", + "tags": [] + }, + { + "key": "Renal / Hepatic", + "val": "MANDATORY — Halve dose in moderate hepatic impairment. Avoid entirely if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Celebrex", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (100 mg, 200 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for chronic arthritis.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Osteoarthritis, Rheumatoid arthritis, Ankylosing spondylitis, acute pain.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The NSAID of choice for patients with a history of peptic ulcer disease who absolutely require anti-inflammatory therapy.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe Ischemic Heart Disease, prior stroke/MI, active GI bleeding, severe heart failure.", + "tags": [] + }, + { + "key": "Allergy", + "val": "CONTRAINDICATED — Celecoxib is contraindicated in sulfonamide allergy or hypersensitivity to celecoxib/excipients.", + "tags": [], + "patient": { + "factors": ["allergy-sulfa"], + "action": "contraindication", + "severity": "danger", + "note": "Celecoxib is contraindicated in sulfonamide allergy or celecoxib hypersensitivity." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category B3 (Avoid in 3rd trimester).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Fluconazole (Inhibits CYP2C9, massively spiking Celecoxib levels. Halve Celecoxib dose).", + "tags": [] + }, + { + "key": "Triple Whammy", + "val": "CRITICAL — ACEi + Diuretic + Celecoxib = AKI.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **BP** regularly. Fluid retention can easily tip an elderly patient into heart failure.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Laboratory", + "val": "Check **U&E** and **eGFR**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Vioxx Ghost", + "val": "Early COX-2 inhibitors (Rofecoxib/Vioxx) were pulled from the market globally because they caused massive fatal heart attacks. Celecoxib survived because its COX-2 selectivity is much weaker. However, the cardiac risk is still very real in high-risk patients.", + "tags": [] + }, + { + "key": "The Renal Truth", + "val": "Many junior doctors assume a 'safer' NSAID is safer for the kidneys. This is false. COX-2 is heavily involved in renal blood flow. Celecoxib will destroy the kidneys just as fast as Diclofenac in a dehydrated patient.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selectively blocks Cyclooxygenase-2 (COX-2), which is induced at sites of inflammation. Spares Cyclooxygenase-1 (COX-1), which produces the protective prostaglandins in the stomach and regulates platelets.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "11 hours. Metabolised primarily by CYP2C9.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: CELEBREX/celecoxib Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "COX-2 Inhibitor — Highly selective COX-2 inhibitor ('Coxib')." + }, + { + "label": "Route / Formulation", + "value": "Capsules (100 mg, 200 mg). (Celebrex)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 100-200 mg **OD** or divided **BD**. Max **400 mg/day** (e.g., 200 mg BD)." + }, + { + "label": "Key Indication Doses", + "value": "Osteoarthritis / RA: **PO** 100-200 mg **OD** or divided **BD**. Acute Pain / Dysmenorrhoea: **PO** 400 mg STAT on Day 1, then 200 mg **BD**. Renal / Hepatic: Halve dose in moderate hepatic impairment. Avoid entirely if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Celecoxib is a selective COX-2 inhibitor with lower GI bleeding risk than traditional NSAIDs, but carries the same cardiovascular risk and is contraindicated in sulfonamide allergy." + }, + { + "label": "Avoid / Cautions", + "value": "Severe Ischemic Heart Disease, prior stroke/MI, active GI bleeding, severe heart failure. **Pregnancy** Category B3 (Avoid in 3rd trimester)." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Increased risk of myocardial infarction, stroke, heart failure, and hypertension. (Selectively blocking COX-2 drops prostacyclin—a vasodilator—while leaving COX-1 thromboxane—a clot promoter—unopposed). Renal: AKI, fluid retention, hyperkalemia. (COX-2 selectivity does NOT protect the kidneys. The renal risk is identical to Ibuprofen). Gastrointestinal: Ulcers and bleeding are significantly reduced compared to standard NSAIDs, but risk is not zero." + }, + { + "label": "Key Interactions", + "value": "Fluconazole (Inhibits CYP2C9, massively spiking Celecoxib levels. Halve Celecoxib dose). ACEi + Diuretic + Celecoxib = AKI." + }, + { + "label": "Monitoring", + "value": "Monitor **BP** regularly. Fluid retention can easily tip an elderly patient into heart failure. Check **U&E** and **eGFR**." + }, + { + "label": "Clinical Pearl", + "value": "Early COX-2 inhibitors (Rofecoxib/Vioxx) were pulled from the market globally because they caused massive fatal heart attacks. Celecoxib survived because its COX-2 selectivity is much weaker. However, the cardiac risk is still very real in high-risk patients." + } + ] + }, + { + "slug": "diclofenac", + "name": "Diclofenac", + "class": "Analgesia", + "subclass": "NSAID", + "category": "Analgesia - Simple & NSAIDs", + "accent": "#be123c", + "tag": "NSAID", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "150 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1-2 h", + "cls": "", + "flag": "" + }, + { + "label": "CV Risk", + "value": "HIGHEST NSAID", + "cls": "warn", + "flag": "warn" + }, + { + "label": "GI Bleed", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent NSAID with slightly more selectivity for COX-2 than COX-1. Excellent pain relief, but possesses the highest cardiovascular toxicity of all traditional NSAIDs.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **150 mg/day** (e.g., 50 mg TDS).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Strictly contraindicated in patients with a history of myocardial infarction, stroke, or severe heart failure due to a massive risk of thrombotic events.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Diclofenac is a potent NSAID available in multiple formulations for acute pain and inflammation, but has the highest cardiovascular risk of common NSAIDs and should be avoided in cardiac patients.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Significant, dose-dependent increased risk of myocardial infarction and stroke. Triggers acute heart failure via sodium retention.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Peptic ulceration and bleeding (despite leaning toward COX-2, GI toxicity remains high).", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal", + "val": "HIGH — AKI (vasoconstricts afferent arteriole).", + "tags": [] + }, + { + "key": "Hepatic", + "val": "MODERATE — Rare but severe hepatotoxicity (highest risk among NSAIDs).", + "tags": [], + "patient": { + "factors": ["hepatic", "allergy-nsaid"], + "action": "dose-adjust", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Pain / Arthritis", + "val": "**PO** 50 mg **TDS**. Max 150 mg/day.", + "tags": [] + }, + { + "key": "Renal Colic (Hospital)", + "val": "**IM** 75 mg STAT deep intragluteal injection. OR **PR** 100 mg suppository.", + "tags": [] + }, + { + "key": "Topical Analgesia", + "val": "Apply 1% or 2% gel **Topical** to affected joint QID.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Voltaren, Voltaren Rapid, Fenac", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (25, 50 mg). Enteric Coated (50 mg). Sustained Release (75, 100 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (75 mg/3 mL) for **IM** only. Suppositories (100 mg) for **PR**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC 25mg). Prescription S4 for higher doses/injections.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute musculoskeletal pain, acute gout, renal colic, rheumatoid arthritis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Used for severe, sharp acute pain (like renal colic) where rapid anti-inflammatory action is required.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Ischemic heart disease, previous stroke/TIA, NYHA Class II-IV heart failure, active GI ulcer, **eGFR** < 30.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Diclofenac is contraindicated in severe renal impairment." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. Do not use in 3rd trimester.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — DOACs, Warfarin, Clopidogrel (GI Bleeding).", + "tags": [] + }, + { + "key": "Triple Whammy", + "val": "CRITICAL — ACEi/ARB + Diuretic + Diclofenac = AKI.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Lithium (massively raises lithium levels).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure patient takes it with food. Strongly consider prophylactic PPI. Avoid prolonged courses (> 2 weeks) if possible due to CV risk.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **LFTs** if used chronically for arthritis.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Colic Missile", + "val": "For a patient writhing in agony from a kidney stone (renal colic), a 100mg Diclofenac suppository (**PR**) is often vastly superior to IV Morphine. It directly halts the prostaglandin-driven ureteric spasm.", + "tags": [] + }, + { + "key": "The Rapid Deception", + "val": "Voltaren Rapid contains diclofenac *potassium*, which dissolves and absorbs in 20 minutes. Standard Voltaren contains diclofenac *sodium* (enteric-coated), which takes hours to absorb. Use 'Rapid' for acute headaches/sprains.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits both COX-1 and COX-2, but leans more heavily toward COX-2 inhibition compared to Ibuprofen. This provides potent anti-inflammatory action but skews the thromboxane/prostacyclin balance in the blood toward clotting.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** (Rapid form) 20 mins. **IM** 15 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "6-8 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-2 hours. Extensive first-pass metabolism.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: VOLTAREN/diclofenac Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "NSAID — Highly potent NSAID with slightly more selectivity for COX-2 than COX-1." + }, + { + "label": "Route / Formulation", + "value": "Tablets (25, 50 mg). Enteric Coated (50 mg). Sustained Release (75, 100 mg). (Voltaren, Voltaren Rapid, Fenac)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 50 mg **TDS**. Max 150 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Acute Pain / Arthritis: **PO** 50 mg **TDS**. Max 150 mg/day. Renal Colic (Hospital): **IM** 75 mg STAT deep intragluteal injection. OR **PR** 100 mg suppository. Topical Analgesia: Apply 1% or 2% gel **Topical** to affected joint QID." + }, + { + "label": "Best Uses", + "value": "Diclofenac is a potent NSAID available in multiple formulations for acute pain and inflammation, but has the highest cardiovascular risk of common NSAIDs and should be avoided in cardiac patients." + }, + { + "label": "Avoid / Cautions", + "value": "Ischemic heart disease, previous stroke/TIA, NYHA Class II-IV heart failure, active GI ulcer, **eGFR** < 30. **Pregnancy** Category C. Do not use in 3rd trimester." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Significant, dose-dependent increased risk of myocardial infarction and stroke. Triggers acute heart failure via sodium retention. Gastrointestinal: Peptic ulceration and bleeding (despite leaning toward COX-2, GI toxicity remains high). Renal: AKI (vasoconstricts afferent arteriole). Hepatic: Rare but severe hepatotoxicity (highest risk among NSAIDs)." + }, + { + "label": "Key Interactions", + "value": "DOACs, Warfarin, Clopidogrel (GI Bleeding). ACEi/ARB + Diuretic + Diclofenac = AKI. Lithium (massively raises lithium levels)." + }, + { + "label": "Monitoring", + "value": "Ensure patient takes it with food. Strongly consider prophylactic PPI. Avoid prolonged courses (> 2 weeks) if possible due to CV risk. Check **LFTs** if used chronically for arthritis." + }, + { + "label": "Clinical Pearl", + "value": "For a patient writhing in agony from a kidney stone (renal colic), a 100mg Diclofenac suppository (**PR**) is often vastly superior to IV Morphine. It directly halts the prostaglandin-driven ureteric spasm." + } + ] + }, + { + "slug": "ibuprofen", + "name": "Ibuprofen", + "class": "Analgesia", + "subclass": "NSAID", + "category": "Analgesia - Simple & NSAIDs", + "accent": "#be123c", + "tag": "NSAID", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "2400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "GI Bleed", + "value": "RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Risk", + "value": "MODERATE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Non-selective Non-Steroidal Anti-Inflammatory Drug (NSAID). Highly effective for inflammatory and musculoskeletal pain. Short half-life.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2400 mg/day** (strictly in divided doses, e.g., 400 mg q6h or 800 mg TDS). OTC limits often say 1200 mg/day.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Avoid in patients with asthma, severe kidney disease, or active peptic ulcers.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ibuprofen is a widely available NSAID for pain, inflammation, and fever, but carries significant GI bleeding, cardiovascular, and renal risk especially in elderly and dehydrated patients.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Dyspepsia, gastric ulceration, severe GI haemorrhage/perforation (due to blockade of protective COX-1 prostaglandins in the stomach).", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal", + "val": "HIGH — Acute Kidney Injury (blocks vasodilatory prostaglandins in the afferent arteriole, choking off blood supply to the glomerulus). Fluid retention, hyperkalemia.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Can precipitate acute heart failure via fluid retention. Increases risk of MI/stroke at high chronic doses.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "MODERATE — Can trigger severe bronchospasm in susceptible asthmatics (Aspirin-Exacerbated Respiratory Disease).", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Mild-to-Moderate Pain / Fever", + "val": "**PO** 200-400 mg q4-6h PRN. Max 2400 mg/day.", + "tags": [] + }, + { + "key": "Rheumatoid / Osteoarthritis", + "val": "**PO** 400-800 mg **TDS** to **QID** (Max 2400 mg/day).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Avoid entirely if **eGFR** < 30. Use with extreme caution if eGFR 30-60.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nurofen, Advil, Brufen", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets/Capsules (200, 400 mg). Oral liquid (100 mg/5mL).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** use (Rare, usually reserved for patent ductus arteriosus closure in neonates).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC) for 200 mg. S4 for higher strengths/large packs.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Inflammatory pain, dysmenorrhoea, fever, rheumatoid arthritis, osteoarthritis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Second step on analgesic ladder. The most widely used NSAID due to a relatively fast onset and acceptable safety profile at low doses.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active peptic ulcer disease, severe heart failure (NYHA IV), severe renal impairment, NSAID-sensitive asthma.", + "tags": [], + "patient": { + "factors": ["renal", "allergy-nsaid"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Ibuprofen is contraindicated in severe renal impairment and NSAID-sensitive asthma." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. STRICTLY CONTRAINDICATED in the 3rd trimester (causes premature closure of the fetal ductus arteriosus and oligohydramnios).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Triple Whammy", + "val": "CRITICAL — NSAID + ACEi/ARB + Diuretic. Will virtually guarantee acute renal failure. NEVER prescribe this combination.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Anticoagulants (Warfarin, DOACs) and Antiplatelets (Clopidogrel). Massive increase in fatal GI bleeding.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Blocks the cardioprotective effect of low-dose Aspirin by competing for the COX-1 binding site. Take aspirin 2 hours before ibuprofen.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Take strictly with food or milk to minimize gastric irritation. Co-prescribe a PPI (Pantoprazole) in the elderly or those with ulcer history.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Laboratory", + "val": "Check **U&E** and **eGFR** if using for > 3-5 days in older adults.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Ceiling Effect", + "val": "For pure analgesia, doses > 400mg per dose provide zero extra pain relief, they only increase GI and renal toxicity. Doses up to 800mg are strictly to maximise the anti-inflammatory effect for severe arthritis.", + "tags": [] + }, + { + "key": "The Dehydration Trap", + "val": "Never give an NSAID to a patient with severe vomiting, diarrhea, or hypovolemia. Their kidneys are relying 100% on prostaglandins to keep the afferent arteriole open. Ibuprofen will snap it shut, causing instant renal necrosis.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Reversibly and non-selectively inhibits Cyclooxygenase-1 (COX-1) and Cyclooxygenase-2 (COX-2) enzymes. Blocks the conversion of arachidonic acid to prostaglandins, dampening peripheral inflammation and pain sensitization.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2 hours. Hepatically metabolised, renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: BRUFEN/ibuprofen Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "NSAID — Non-selective Non-Steroidal Anti-Inflammatory Drug (NSAID)." + }, + { + "label": "Route / Formulation", + "value": "Tablets/Capsules (200, 400 mg). Oral liquid (100 mg/5mL). (Nurofen, Advil, Brufen)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 200-400 mg q4-6h PRN. Max 2400 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Mild-to-Moderate Pain / Fever: **PO** 200-400 mg q4-6h PRN. Max 2400 mg/day. Rheumatoid / Osteoarthritis: **PO** 400-800 mg **TDS** to **QID** (Max 2400 mg/day). Renal Impairment: Avoid entirely if **eGFR** < 30. Use with extreme caution if eGFR 30-60." + }, + { + "label": "Best Uses", + "value": "Ibuprofen is a widely available NSAID for pain, inflammation, and fever, but carries significant GI bleeding, cardiovascular, and renal risk especially in elderly and dehydrated patients." + }, + { + "label": "Avoid / Cautions", + "value": "Active peptic ulcer disease, severe heart failure (NYHA IV), severe renal impairment, NSAID-sensitive asthma. **Pregnancy** Category C. STRICTLY CONTRAINDICATED in the 3rd trimester (causes premature closure of the fetal ductus arteriosus and oligohydramnios)." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Dyspepsia, gastric ulceration, severe GI haemorrhage/perforation (due to blockade of protective COX-1 prostaglandins in the stomach). Renal: Acute Kidney Injury (blocks vasodilatory prostaglandins in the afferent arteriole, choking off blood supply to the glomerulus). Fluid retention, hyperkalemia. Cardiovascular: Can precipitate acute heart failure via fluid retention. Increases risk of MI/stroke at high chronic doses. Respiratory: Can trigger severe bronchospasm in susceptible asthmatics (Aspirin-Exacerbated Respiratory Disease)." + }, + { + "label": "Key Interactions", + "value": "NSAID + ACEi/ARB + Diuretic. Will virtually guarantee acute renal failure. NEVER prescribe this combination. Anticoagulants (Warfarin, DOACs) and Antiplatelets (Clopidogrel). Massive increase in fatal GI bleeding. Blocks the cardioprotective effect of low-dose Aspirin by competing for the COX-1 binding site. Take aspirin 2 hours before ibuprofen." + }, + { + "label": "Monitoring", + "value": "Take strictly with food or milk to minimize gastric irritation. Co-prescribe a PPI (Pantoprazole) in the elderly or those with ulcer history. Check **U&E** and **eGFR** if using for > 3-5 days in older adults." + }, + { + "label": "Clinical Pearl", + "value": "For pure analgesia, doses > 400mg per dose provide zero extra pain relief, they only increase GI and renal toxicity. Doses up to 800mg are strictly to maximise the anti-inflammatory effect for severe arthritis." + } + ] + }, + { + "slug": "ketorolac", + "name": "Ketorolac", + "class": "Analgesia", + "subclass": "NSAID", + "category": "Analgesia - Simple & NSAIDs", + "accent": "#be123c", + "tag": "NSAID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "90 mg/day (IV)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Max Duration", + "value": "5 DAYS", + "cls": "hi", + "flag": "warn" + }, + { + "label": "GI Bleed", + "value": "CRITICAL RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Renal Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Intravenously active, aggressively potent NSAID. Provides opioid-level pain relief (equivalent to ~10mg IV Morphine) for severe acute pain (e.g., kidney stones, post-op pain).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **90 mg/day** (IV/IM) or **40 mg/day** (PO).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Black Box Warning: MUST NOT BE USED FOR MORE THAN 5 DAYS TOTAL across all routes. Day 6 carries an unacceptable risk of catastrophic GI hemorrhage and acute renal failure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ketorolac is the most potent injectable NSAID for acute pain, but must be limited to 5 days maximum due to high GI bleeding and renal toxicity risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Peptic ulceration, massive GI haemorrhage, and perforation (Risk skyrockets exponentially after 5 days of use).", + "tags": [] + }, + { + "key": "Renal", + "val": "CRITICAL — Acute Kidney Injury (AKI). Clamps the afferent arteriole shut.", + "tags": [] + }, + { + "key": "Haematological", + "val": "HIGH — Reversibly inhibits platelet aggregation. Do NOT use if surgery is imminent or if bleeding is a risk (e.g., suspected brain bleed).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Severe Pain / Renal Colic", + "val": "**IV** 30 mg STAT (pushed over 15 seconds) or **IM** 30 mg. May repeat 15-30 mg q6h. Max 90 mg/day.", + "tags": [] + }, + { + "key": "Elderly (> 65 yrs) / < 50 kg", + "val": "MANDATORY — Max **60 mg/day**. Start with 15 mg STAT.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Avoid entirely in moderate-to-severe renal impairment (**eGFR** < 50) or in patients who are dehydrated post-op.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 50 + } + }, + "note": "Ketorolac is avoided in moderate-to-severe renal impairment and dehydration because of high NSAID renal toxicity risk." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Toradol", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (10, 30 mg/1 mL) for **IV** or deep **IM** injection.", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg) — rarely used, IV is preferred.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital/OT/ED supply. S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Short-term (≤ 5 days) management of moderately severe acute pain requiring analgesia at the opioid level.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "The absolute gold standard non-opioid 'nuke' in the Emergency Department for renal colic (kidney stones) and severe biliary colic.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Suspected/confirmed GI bleeding, active peptic ulcer disease, bleeding diathesis, CABG surgery, asthma triggered by aspirin (AERD).", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. Do not use in 3rd trimester or during labor (stops uterine contractions and closes fetal ductus).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Triple Whammy", + "val": "CRITICAL — ACEi/ARB + Diuretic + Ketorolac = Renal Necrosis.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Warfarin, DOACs, Prophylactic Heparin (Massive bleeding risk).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the patient is well-hydrated (IV fluids) before pushing the drug to protect the kidneys.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — Check **eGFR** prior to administration if clinically possible.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Renal Colic Magic", + "val": "For a patient writhing in agony from a kidney stone, Ketorolac works better than Morphine. Morphine just masks the pain in the brain. Ketorolac halts the local prostaglandin-driven inflammatory spasm in the ureter itself, attacking the root cause of the pain.", + "tags": [] + }, + { + "key": "The 5-Day Wall", + "val": "If an orthopedic surgeon prescribes 'Ketorolac 30mg IV QID regular' post-op, the ward pharmacist or nurse MUST flag it on Day 5 and ensure the medication is ceased and swapped to standard oral Ibuprofen/Celecoxib.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Reversible, non-selective inhibitor of COX-1 and COX-2. Intensely blocks prostaglandin synthesis in the peripheral tissues and the kidney.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 1-5 mins. Peak effect at 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5-6 hours. Highly protein bound. Renally excreted.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: TORADOL/ketorolac Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "NSAID — Intravenously active, aggressively potent NSAID." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (10, 30 mg/1 mL) for **IV** or deep **IM** injection. (Toradol)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 30 mg STAT (pushed over 15 seconds) or **IM** 30 mg. May repeat 15-30 mg q6h. Max 90 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Acute Severe Pain / Renal Colic: **IV** 30 mg STAT (pushed over 15 seconds) or **IM** 30 mg. May repeat 15-30 mg q6h. Max 90 mg/day. Elderly (> 65 yrs) / < 50 kg: Max **60 mg/day**. Start with 15 mg STAT. Renal Impairment: Avoid entirely in moderate-to-severe renal impairment (**eGFR** < 50) or in patients who are dehydrated post-op." + }, + { + "label": "Best Uses", + "value": "Ketorolac is the most potent injectable NSAID for acute pain, but must be limited to 5 days maximum due to high GI bleeding and renal toxicity risk." + }, + { + "label": "Avoid / Cautions", + "value": "Suspected/confirmed GI bleeding, active peptic ulcer disease, bleeding diathesis, CABG surgery, asthma triggered by aspirin (AERD). **Pregnancy** Category C. Do not use in 3rd trimester or during labor (stops uterine contractions and closes fetal ductus)." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Peptic ulceration, massive GI haemorrhage, and perforation (Risk skyrockets exponentially after 5 days of use). Renal: Acute Kidney Injury (AKI). Clamps the afferent arteriole shut. Haematological: Reversibly inhibits platelet aggregation. Do NOT use if surgery is imminent or if bleeding is a risk (e.g., suspected brain bleed)." + }, + { + "label": "Key Interactions", + "value": "ACEi/ARB + Diuretic + Ketorolac = Renal Necrosis. Warfarin, DOACs, Prophylactic Heparin (Massive bleeding risk)." + }, + { + "label": "Monitoring", + "value": "Ensure the patient is well-hydrated (IV fluids) before pushing the drug to protect the kidneys. Check **eGFR** prior to administration if clinically possible." + }, + { + "label": "Clinical Pearl", + "value": "For a patient writhing in agony from a kidney stone, Ketorolac works better than Morphine. Morphine just masks the pain in the brain. Ketorolac halts the local prostaglandin-driven inflammatory spasm in the ureter itself, attacking the root cause of the pain." + } + ] + }, + { + "slug": "meloxicam", + "name": "Meloxicam", + "class": "Analgesia", + "subclass": "NSAID (COX-2 preferential)", + "category": "Analgesia - Simple & NSAIDs", + "accent": "#be123c", + "tag": "NSAID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "15 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "15-20 h", + "cls": "", + "flag": "" + }, + { + "label": "GI Bleed", + "value": "LOWER RISK", + "cls": "good", + "flag": "" + }, + { + "label": "Renal Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Preferential COX-2 inhibitor. Highly effective for osteoarthritis and rheumatoid arthritis. Provides a middle ground between the GI toxicity of traditional NSAIDs and the cardiovascular risk of pure COX-2 inhibitors.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **15 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly bound to plasma proteins. Extremely long half-life allows once-daily dosing, but increases the risk of accumulation in renal impairment.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Meloxicam is a preferential COX-2 NSAID with once-daily dosing for osteoarthritis and rheumatoid arthritis, but carries the same cardiovascular and renal risks as non-selective NSAIDs.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Peptic ulceration, GI bleeding. (Safer than Naproxen at 7.5mg, but identical risk at 15mg).", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal", + "val": "CRITICAL — Acute Kidney Injury (AKI), fluid retention, hyperkalemia.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Hypertension, mild increased risk of thrombotic events.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Osteoarthritis / Rheumatoid Arthritis", + "val": "**PO** 7.5 - 15 mg **OD** (Take with food).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Max 7.5 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Avoid entirely if **eGFR** < 30. (Reduces renal prostaglandins, causing severe AKI).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Mobic, Moxicam", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (7.5 mg, 15 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Symptomatic treatment of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Excellent choice for chronic arthritic pain due to once-daily dosing and slightly better GI tolerance than Diclofenac or Naproxen.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active GI bleeding, severe heart failure, **eGFR** < 30.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Meloxicam is contraindicated/avoided in severe renal impairment." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. Contraindicated in 3rd trimester.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Triple Whammy", + "val": "CRITICAL — NSAID + ACEi/ARB + Diuretic = AKI.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Anticoagulants (DOACs/Warfarin). Massive GI bleeding risk.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Lithium and Methotrexate (Reduces their renal clearance, causing toxic spikes).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Take strictly with food. Co-prescribe a PPI (Pantoprazole) in vulnerable patients.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **U&E** and **eGFR** if used long-term.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Dose Threshold", + "val": "At 7.5mg, Meloxicam is relatively COX-2 selective and gentle on the stomach. At 15mg, it loses this selectivity and behaves exactly like a traditional, harsh NSAID like Diclofenac. Respect the 7.5mg dose in the elderly.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Reversibly inhibits cyclooxygenase enzymes, with a preference for COX-2 over COX-1 (though this preference is lost at the max 15mg dose).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2-3 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "15-20 hours. Heavily metabolised by CYP2C9.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: MOBIC/meloxicam Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "NSAID (COX-2 preferential) — Preferential COX-2 inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (7.5 mg, 15 mg). (Mobic, Moxicam)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 7.5 - 15 mg **OD** (Take with food). Max **15 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Osteoarthritis / Rheumatoid Arthritis: **PO** 7.5 - 15 mg **OD** (Take with food). Elderly / Frail: Max 7.5 mg **OD**. Renal Impairment: Avoid entirely if **eGFR** < 30. (Reduces renal prostaglandins, causing severe AKI)." + }, + { + "label": "Best Uses", + "value": "Meloxicam is a preferential COX-2 NSAID with once-daily dosing for osteoarthritis and rheumatoid arthritis, but carries the same cardiovascular and renal risks as non-selective NSAIDs." + }, + { + "label": "Avoid / Cautions", + "value": "Active GI bleeding, severe heart failure, **eGFR** < 30. **Pregnancy** Category C. Contraindicated in 3rd trimester." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Peptic ulceration, GI bleeding. (Safer than Naproxen at 7.5mg, but identical risk at 15mg). Renal: Acute Kidney Injury (AKI), fluid retention, hyperkalemia. Cardiovascular: Hypertension, mild increased risk of thrombotic events." + }, + { + "label": "Key Interactions", + "value": "NSAID + ACEi/ARB + Diuretic = AKI. Anticoagulants (DOACs/Warfarin). Massive GI bleeding risk. Lithium and Methotrexate (Reduces their renal clearance, causing toxic spikes)." + }, + { + "label": "Monitoring", + "value": "Take strictly with food. Co-prescribe a PPI (Pantoprazole) in vulnerable patients. Check **U&E** and **eGFR** if used long-term." + }, + { + "label": "Clinical Pearl", + "value": "At 7.5mg, Meloxicam is relatively COX-2 selective and gentle on the stomach. At 15mg, it loses this selectivity and behaves exactly like a traditional, harsh NSAID like Diclofenac. Respect the 7.5mg dose in the elderly." + } + ] + }, + { + "slug": "naproxen", + "name": "Naproxen", + "class": "Analgesia", + "subclass": "NSAID", + "category": "Analgesia - Simple & NSAIDs", + "accent": "#be123c", + "tag": "NSAID", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "1000 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12-15 h", + "cls": "", + "flag": "" + }, + { + "label": "GI Bleed", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "CV Risk", + "value": "LOWER", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent, long-acting non-selective NSAID. Highly effective for gout and rheumatological conditions. Has the safest cardiovascular profile of all NSAIDs.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1000 mg/day** (1250 mg/day on day 1 for acute gout).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Higher risk of severe GI bleeding compared to ibuprofen due to its long half-life. Cover with a PPI in vulnerable patients.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Naproxen is the NSAID with the best cardiovascular safety profile for patients requiring long-term anti-inflammatory therapy, but still carries GI bleeding and renal risks common to all NSAIDs.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Peptic ulceration, perforation, and GI bleeding. Higher risk than ibuprofen due to prolonged COX-1 blockade in the stomach.", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal", + "val": "HIGH — AKI, fluid retention, hyperkalemia.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Has the most favorable, neutral cardiovascular risk profile (lowest risk of causing an MI) compared to Diclofenac or Celecoxib.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Gout", + "val": "**PO** 750 mg STAT, then 250 mg every 8 hours until attack resolves. Max 1250 mg on Day 1, then 1000 mg/day.", + "tags": [] + }, + { + "key": "Rheumatoid / Osteoarthritis", + "val": "**PO** 250-500 mg **BD** (morning and night).", + "tags": [] + }, + { + "key": "Dysmenorrhoea", + "val": "**PO** 500 mg STAT, then 250 mg q6-8h. Max 1250 mg on Day 1.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Avoid if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Naprogesic, Naprosyn, Inza", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (250, 500 mg). Enteric-coated (SR) tablets (500, 750 mg, 1000 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC) for 275mg low dose. S4 for higher doses. Unrestricted General Benefit.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute gout, rheumatoid arthritis, dysmenorrhoea, acute musculoskeletal injuries.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The NSAID of choice for patients with known ischemic heart disease who absolutely require an NSAID (due to its neutral CV risk profile).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active GI bleeding, severe heart failure, **eGFR** < 30.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Naproxen is contraindicated/avoided in severe renal impairment." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. Do not use in 3rd trimester (premature ductus arteriosus closure).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Triple Whammy", + "val": "CRITICAL — NSAID + ACEi/ARB + Diuretic = AKI.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Anticoagulants (DOACs/Warfarin). High risk of fatal upper GI bleed.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Lithium and Methotrexate (Naproxen heavily blocks their renal clearance, causing toxic spikes).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Take strictly with food. A prophylactic PPI (Pantoprazole 20-40mg) is heavily recommended for patients >65 years or those on Aspirin/SSRIs.", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "monitor", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Laboratory", + "val": "Check **U&E** if used long-term.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Gout Hammer", + "val": "Naproxen is the absolute gold-standard NSAID for an acute gout flare. A massive 750mg stat dose rapidly crushes the inflammation faster than most other oral agents.", + "tags": [] + }, + { + "key": "The Cardiac Choice", + "val": "If a patient with a history of stents or MI has crippling arthritis and demands an NSAID, Naproxen is the only one backed by data to not significantly increase their risk of a repeat heart attack.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Reversibly inhibits COX-1 and COX-2. Potent anti-inflammatory action.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1 hour.", + "tags": [] + }, + { + "key": "Duration", + "val": "Up to 12 h (Allows for convenient **BD** dosing).", + "tags": [] + }, + { + "key": "Half-life", + "val": "12-15 hours. Highly protein bound (99%).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: NAPROSYN/naproxen Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "NSAID — Potent, long-acting non-selective NSAID." + }, + { + "label": "Route / Formulation", + "value": "Tablets (250, 500 mg). Enteric-coated (SR) tablets (500, 750 mg, 1000 mg). (Naprogesic, Naprosyn, Inza)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 750 mg STAT, then 250 mg every 8 hours until attack resolves. Max 1250 mg on Day 1, then 1000 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Acute Gout: **PO** 750 mg STAT, then 250 mg every 8 hours until attack resolves. Max 1250 mg on Day 1, then 1000 mg/day. Rheumatoid / Osteoarthritis: **PO** 250-500 mg **BD** (morning and night). Dysmenorrhoea: **PO** 500 mg STAT, then 250 mg q6-8h. Max 1250 mg on Day 1. Renal Impairment: Avoid if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Naproxen is the NSAID with the best cardiovascular safety profile for patients requiring long-term anti-inflammatory therapy, but still carries GI bleeding and renal risks common to all NSAIDs." + }, + { + "label": "Avoid / Cautions", + "value": "Active GI bleeding, severe heart failure, **eGFR** < 30. **Pregnancy** Category C. Do not use in 3rd trimester (premature ductus arteriosus closure)." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Peptic ulceration, perforation, and GI bleeding. Higher risk than ibuprofen due to prolonged COX-1 blockade in the stomach. Renal: AKI, fluid retention, hyperkalemia. Cardiovascular: Has the most favorable, neutral cardiovascular risk profile (lowest risk of causing an MI) compared to Diclofenac or Celecoxib." + }, + { + "label": "Key Interactions", + "value": "NSAID + ACEi/ARB + Diuretic = AKI. Anticoagulants (DOACs/Warfarin). High risk of fatal upper GI bleed. Lithium and Methotrexate (Naproxen heavily blocks their renal clearance, causing toxic spikes)." + }, + { + "label": "Monitoring", + "value": "Take strictly with food. A prophylactic PPI (Pantoprazole 20-40mg) is heavily recommended for patients >65 years or those on Aspirin/SSRIs. Check **U&E** if used long-term." + }, + { + "label": "Clinical Pearl", + "value": "Naproxen is the absolute gold-standard NSAID for an acute gout flare. A massive 750mg stat dose rapidly crushes the inflammation faster than most other oral agents." + } + ] + }, + { + "slug": "paracetamol", + "name": "Paracetamol", + "class": "Analgesia", + "subclass": "Simple Analgesic", + "category": "Analgesia - Simple & NSAIDs", + "accent": "#be123c", + "tag": "ANALGESIC", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "4 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "Hepatotoxicity", + "value": "IN OD", + "cls": "hi", + "flag": "warn" + }, + { + "label": "GI Risk", + "value": "LOW", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The foundational, universally prescribed analgesic and antipyretic. Safe for the stomach and kidneys, but lethally hepatotoxic in overdose.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 g/day** (strictly 1 g q6h). Must be reduced in severe liver failure or malnourishment.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The leading cause of acute liver failure worldwide. Always calculate cumulative dose across all combo products (e.g., Panadeine).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Paracetamol is the safest first-line analgesic and antipyretic for mild-moderate pain, but hepatotoxicity in overdose is the leading cause of acute liver failure and the therapeutic window is narrow.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Hepatic", + "val": "CRITICAL — Centrilobular hepatic necrosis (fatal liver failure) in overdose (>10g or >200mg/kg).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Cardiovascular", + "val": "MODERATE — **IV** administration can cause transient hypotension if infused too rapidly.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "SAFE — Zero risk of peptic ulcer disease or GI bleeding (unlike NSAIDs).", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Pain / Fever (Adults)", + "val": "**PO** / **IV** 500 mg - 1 g q4-6h. Max 4 g/day.", + "tags": [] + }, + { + "key": "Elderly / Frail / < 50 kg", + "val": "MANDATORY — Max **3 g/day** (or 60 mg/kg/day).", + "tags": [] + }, + { + "key": "Severe Hepatic Impairment", + "val": "MANDATORY — Max **2-3 g/day** or avoid entirely if acute fulminant failure.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Panadol, Panamax, Perfalgan (IV)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets/Capsules (500 mg). Modified Release (665 mg - Osteo). Oral liquid.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-mixed vials (1 g/100 mL) for **IV** infusion. Suppositories for **PR** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (PO). S4 for IV.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Mild-to-moderate pain, fever.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First step on the WHO analgesic ladder. Should be co-prescribed regularly with all opioids to enact 'opioid-sparing' synergy.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Acute fulminant liver failure, known hypersensitivity.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Existing absolute row names active or severe hepatic disease/failure; highlight when hepatic context is entered." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. The analgesic of choice in pregnancy and lactation.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "info", + "severity": "info", + "note": "Paracetamol pregnancy/lactation row is informational and should not trigger an automatic contraindication alert." + } + }, + { + "key": "Renal Impairment", + "val": "SAFE — Does not impair renal prostaglandins. Safe in CKD/AKI.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "info", + "severity": "info", + "note": "Paracetamol renal row is informational and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Chronic heavy alcohol use depletes glutathione stores and upregulates CYP2E1, drastically increasing the amount of toxic NAPQI produced. Alcoholics are at high risk of liver failure even at standard 4g/day doses.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — IV Flucloxacillin. Co-administration with high-dose paracetamol causes severe High Anion Gap Metabolic Acidosis (HAGMA) due to 5-oxoproline accumulation (especially in malnourished women).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — In overdose, plot serum paracetamol level against the Rumack-Matthew nomogram to dictate the need for Acetylcysteine (antidote). Monitor **LFTs** and **INR** (liver synthetic function).", + "tags": [] + }, + { + "key": "Bedside", + "val": "Ensure doses are spaced by at least 4 hours.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Panadeine Trap", + "val": "Patients often don't realise 'Panadeine Forte' or cold/flu sachets contain 500mg of paracetamol. They take 4g of standard Panadol on top of their combo pills, accidentally overdosing to 8g/day. Always reconcile combos.", + "tags": [] + }, + { + "key": "IV vs PO", + "val": "IV paracetamol costs 100x more than PO and provides no superior analgesic benefit once the gut is functioning. Step down to oral as soon as the patient is absorbing fluids.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Exact mechanism debated. Reversibly inhibits COX-3 (a central splice variant of COX-1) in the brain, reducing prostaglandin synthesis centrally. Zero peripheral anti-inflammatory action.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30 mins. **IV** 10 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2 hours. Hepatically metabolised (Glucuronidation/Sulfation). 5% is converted via CYP2E1 into the highly toxic NAPQI metabolite, which is normally neutralized by glutathione.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: PANADOL/paracetamol Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Simple Analgesic — The foundational, universally prescribed analgesic and antipyretic." + }, + { + "label": "Route / Formulation", + "value": "Tablets/Capsules (500 mg). Modified Release (665 mg - Osteo). Oral liquid. (Panadol, Panamax, Perfalgan (IV))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** / **IV** 500 mg - 1 g q4-6h. Max 4 g/day." + }, + { + "label": "Key Indication Doses", + "value": "Pain / Fever (Adults): **PO** / **IV** 500 mg - 1 g q4-6h. Max 4 g/day. Elderly / Frail / < 50 kg: Max **3 g/day** (or 60 mg/kg/day). Severe Hepatic Impairment: Max **2-3 g/day** or avoid entirely if acute fulminant failure." + }, + { + "label": "Best Uses", + "value": "Paracetamol is the safest first-line analgesic and antipyretic for mild-moderate pain, but hepatotoxicity in overdose is the leading cause of acute liver failure and the therapeutic window is narrow." + }, + { + "label": "Avoid / Cautions", + "value": "Acute fulminant liver failure, known hypersensitivity. **Pregnancy** Category A. The analgesic of choice in pregnancy and lactation." + }, + { + "label": "Key Risks", + "value": "Hepatic: Centrilobular hepatic necrosis (fatal liver failure) in overdose (>10g or >200mg/kg). Cardiovascular: **IV** administration can cause transient hypotension if infused too rapidly. Gastrointestinal: Zero risk of peptic ulcer disease or GI bleeding (unlike NSAIDs)." + }, + { + "label": "Key Interactions", + "value": "Chronic heavy alcohol use depletes glutathione stores and upregulates CYP2E1, drastically increasing the amount of toxic NAPQI produced. Alcoholics are at high risk of liver failure even at standard 4g/day doses. IV Flucloxacillin. Co-administration with high-dose paracetamol causes severe High Anion Gap Metabolic Acidosis (HAGMA) due to 5-oxoproline accumulation (especially in malnourished women)." + }, + { + "label": "Monitoring", + "value": "In overdose, plot serum paracetamol level against the Rumack-Matthew nomogram to dictate the need for Acetylcysteine (antidote). Monitor **LFTs** and **INR** (liver synthetic function). Ensure doses are spaced by at least 4 hours." + }, + { + "label": "Clinical Pearl", + "value": "Patients often don't realise 'Panadeine Forte' or cold/flu sachets contain 500mg of paracetamol. They take 4g of standard Panadol on top of their combo pills, accidentally overdosing to 8g/day. Always reconcile combos." + } + ] + }, + { + "slug": "parecoxib", + "name": "Parecoxib", + "class": "Analgesia", + "subclass": "COX-2 Inhibitor (Injectable)", + "category": "Analgesia - Simple & NSAIDs", + "accent": "#be123c", + "tag": "NSAID IV/IM", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "80 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "22 mins (Act: 8h)", + "cls": "", + "flag": "" + }, + { + "label": "CV Risk", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Risk", + "value": "MODERATE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The only injectable highly selective COX-2 inhibitor. An absolute powerhouse for post-operative multimodal analgesia, sparing the gut while heavily sparing opioid use.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **80 mg/day** (e.g., 40 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "It is a prodrug that rapidly converts to valdecoxib. Carries the same severe cardiovascular and renal risks as all NSAIDs. Do not use post-CABG.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Parecoxib is the only injectable COX-2 inhibitor for acute post-operative pain, but carries cardiovascular risk with prolonged use and is contraindicated after CABG surgery.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Myocardial infarction, stroke, heart failure. Strictly contraindicated post-Coronary Artery Bypass Graft (CABG) surgery.", + "tags": [] + }, + { + "key": "Renal", + "val": "HIGH — Acute Kidney Injury (AKI), especially in hypovolemic post-op patients.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Peptic ulcer risk is significantly lower than Ketorolac or Diclofenac, but not zero.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Post-Operative Pain", + "val": "**IV** or **IM** 40 mg STAT, then 40 mg **OD** or 20-40 mg **BD**. Max 80 mg/day.", + "tags": [] + }, + { + "key": "Elderly / < 50 kg", + "val": "MANDATORY — Halve the dose. Start with 20 mg STAT. Max 40 mg/day.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Avoid entirely if **eGFR** < 30. Use extreme caution if dehydrated post-op.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dynastat", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (40 mg powder) for reconstitution. For **IV** push or deep **IM** injection.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital/OT supply. Restricted for peri-operative use.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Short-term management of acute postoperative pain.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Given by anesthetists intra-operatively or prescribed on the ward for 1-3 days post-op to rapidly drop opioid requirements.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Post-CABG surgery, active GI bleed, severe heart failure, severe hepatic/renal impairment, severe sulfa allergy.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic", "allergy-sulfa"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Parecoxib is contraindicated in severe renal/hepatic impairment and severe sulfonamide allergy." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. Contraindicated in 3rd trimester.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Triple Whammy", + "val": "CRITICAL — ACEi/ARB + Diuretic + Parecoxib = High risk of post-op renal failure.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Fluconazole (CYP2C9 inhibitor) increases valdecoxib levels. Halve parecoxib dose.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the patient is adequately hydrated (IV fluids or PO) before administration to protect the kidneys.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor **U&E** and **eGFR** daily post-op.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The CABG Ban", + "val": "Parecoxib is brilliant for orthopedic or general surgery, but it is globally black-listed for cardiac surgery (CABG) because it causes a massive spike in fatal post-op thrombotic events (heart attacks/strokes).", + "tags": [] + }, + { + "key": "The Opioid Sparing Synergy", + "val": "A 40mg dose of Parecoxib provides the equivalent pain relief of ~10mg of IV Morphine, but without any respiratory depression or constipation. It is essential for ERAS (Enhanced Recovery After Surgery) pathways.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug. Rapidly hydrolyzed by liver enzymes to valdecoxib, which selectively blocks COX-2, stopping prostaglandin synthesis at the surgical wound site.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 7-13 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Parecoxib: 22 mins. Valdecoxib (active): 8 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: DYNASTAT/parecoxib Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "COX-2 Inhibitor (Injectable) — The only injectable highly selective COX-2 inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Vials (40 mg powder) for reconstitution. For **IV** push or deep **IM** injection. (Dynastat)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** or **IM** 40 mg STAT, then 40 mg **OD** or 20-40 mg **BD**. Max 80 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Post-Operative Pain: **IV** or **IM** 40 mg STAT, then 40 mg **OD** or 20-40 mg **BD**. Max 80 mg/day. Elderly / < 50 kg: Halve the dose. Start with 20 mg STAT. Max 40 mg/day. Renal Impairment: Avoid entirely if **eGFR** < 30. Use extreme caution if dehydrated post-op." + }, + { + "label": "Best Uses", + "value": "Parecoxib is the only injectable COX-2 inhibitor for acute post-operative pain, but carries cardiovascular risk with prolonged use and is contraindicated after CABG surgery." + }, + { + "label": "Avoid / Cautions", + "value": "Post-CABG surgery, active GI bleed, severe heart failure, severe hepatic/renal impairment, severe sulfa allergy. **Pregnancy** Category C. Contraindicated in 3rd trimester." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Myocardial infarction, stroke, heart failure. Strictly contraindicated post-Coronary Artery Bypass Graft (CABG) surgery. Renal: Acute Kidney Injury (AKI), especially in hypovolemic post-op patients. Gastrointestinal: Peptic ulcer risk is significantly lower than Ketorolac or Diclofenac, but not zero." + }, + { + "label": "Key Interactions", + "value": "ACEi/ARB + Diuretic + Parecoxib = High risk of post-op renal failure. Fluconazole (CYP2C9 inhibitor) increases valdecoxib levels. Halve parecoxib dose." + }, + { + "label": "Monitoring", + "value": "Ensure the patient is adequately hydrated (IV fluids or PO) before administration to protect the kidneys. Monitor **U&E** and **eGFR** daily post-op." + }, + { + "label": "Clinical Pearl", + "value": "Parecoxib is brilliant for orthopedic or general surgery, but it is globally black-listed for cardiac surgery (CABG) because it causes a massive spike in fatal post-op thrombotic events (heart attacks/strokes)." + } + ] + }, + { + "slug": "bupivacaine", + "name": "Bupivacaine", + "class": "Local Anaesthetic", + "subclass": "Amide Anaesthetic", + "category": "Analgesia - Topicals & Local", + "accent": "#be123c", + "tag": "INJECTABLE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "2 mg/kg", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3 h", + "cls": "", + "flag": "" + }, + { + "label": "Cardiotoxic", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Intralipid", + "value": "ANTIDOTE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent, long-acting amide local anaesthetic. The cornerstone of epidurals, spinals, and major regional nerve blocks.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2 mg/kg** (without adrenaline). Absolute maximum single dose ~150 mg.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Bupivacaine is intensely cardiotoxic. Accidental IV injection causes refractory ventricular fibrillation (VF) that resists standard CPR/defibrillation.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Bupivacaine is a long-acting local anaesthetic for regional blocks and epidurals, but is the most cardiotoxic local anaesthetic and accidental IV injection can cause fatal cardiac arrest.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Local Anaesthetic Systemic Toxicity (LAST). Bupivacaine tightly binds cardiac fast sodium channels, causing widening of the QRS, bradycardia, complete heart block, and refractory VF/Asystole.", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — LAST (CNS phase): Perioral numbness, metallic taste, tinnitus, leading to sudden violent seizures and coma.", + "tags": [] + }, + { + "key": "Tissue", + "val": "LOW — Chondrotoxicity (can destroy cartilage if injected directly into a joint space continuously).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Local Infiltration / Nerve Block", + "val": "**SC** / **Perineural** 0.25% or 0.5% solution. Dose strictly calculated by weight. Aspiration prior to injection is mandatory to rule out intravascular placement.", + "tags": [] + }, + { + "key": "Epidural Infusion", + "val": "**Epidural** 0.1% or 0.125% (often combined with fentanyl) run continuously.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Marcain, Marcain with Adrenaline", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules/Vials (0.25%, 0.5%, 0.75%). High concentrations (0.75%) are contraindicated in obstetrics.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital/OT supply. Restricted.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Surgical anaesthesia, epidural analgesia (labor/post-op), prolonged peripheral nerve blocks.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Provides hours of pain relief compared to the minutes/hour provided by Lidocaine. Essential for major surgery.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Intravenous Regional Anaesthesia (Bier Block) — fatal if the tourniquet fails. Pre-existing severe heart block.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category A. The 0.75% formulation is strictly banned in epidurals for labor due to historical maternal cardiac arrests.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Bupivacaine pregnancy row is a formulation/route-specific caution rather than an automatic pregnancy contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive toxicity with other local anaesthetics. You must calculate the TOTAL cumulative dose if the patient has had a Lidocaine block and a Bupivacaine epidural.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Aspiration before injecting every 3-5 mL is critical to ensure you are not in a blood vessel. Resuscitation equipment and Intralipid 20% MUST be immediately available in the room.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Continuous **ECG** monitoring during large volume nerve blocks.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Intralipid Rescue", + "val": "If accidental IV injection occurs and the patient arrests, standard ALS (Adrenaline) often fails because the Bupivacaine is locked onto the cardiac receptors. You MUST administer Intralipid 20% IV. The lipid emulsion acts as a 'lipid sink', physically drawing the highly lipophilic Bupivacaine out of the heart tissue and saving the patient's life.", + "tags": [] + }, + { + "key": "The Ropivacaine Swap", + "val": "Due to bupivacaine's terrifying cardiac profile, many hospitals now exclusively use Ropivacaine (Naropin) for epidurals and blocks, as it provides identical pain relief with significantly less motor block and less cardiotoxicity.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to the intracellular portion of voltage-gated sodium channels, locking them in the inactive state and blocking action potential propagation. High affinity for cardiac sodium channels (hence the extreme cardiotoxicity).", + "tags": [] + }, + { + "key": "Onset", + "val": "10-20 mins (Slower onset than Lidocaine).", + "tags": [] + }, + { + "key": "Duration", + "val": "4-8 h (Highly protein bound, stays at the nerve site).", + "tags": [] + }, + { + "key": "Half-life", + "val": "3 hours. Hepatically metabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: Bupivacaine Injection BP Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Amide Anaesthetic — Highly potent, long-acting amide local anaesthetic." + }, + { + "label": "Route / Formulation", + "value": "Ampoules/Vials (0.25%, 0.5%, 0.75%). High concentrations (0.75%) are contraindicated in obstetrics. (Marcain, Marcain with Adrenaline)" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** / **Perineural** 0.25% or 0.5% solution. Dose strictly calculated by weight. Aspiration prior to injection is mandatory to rule out intravascular placement. Max **2 mg/kg** (without adrenaline). Absolute maximum single dose ~150 mg." + }, + { + "label": "Key Indication Doses", + "value": "Local Infiltration / Nerve Block: **SC** / **Perineural** 0.25% or 0.5% solution. Dose strictly calculated by weight. Aspiration prior to injection is mandatory to rule out intravascular placement. Epidural Infusion: **Epidural** 0.1% or 0.125% (often combined with fentanyl) run continuously." + }, + { + "label": "Best Uses", + "value": "Bupivacaine is a long-acting local anaesthetic for regional blocks and epidurals, but is the most cardiotoxic local anaesthetic and accidental IV injection can cause fatal cardiac arrest." + }, + { + "label": "Avoid / Cautions", + "value": "Intravenous Regional Anaesthesia (Bier Block) — fatal if the tourniquet fails. Pre-existing severe heart block. **Pregnancy** Category A. The 0.75% formulation is strictly banned in epidurals for labor due to historical maternal cardiac arrests." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Local Anaesthetic Systemic Toxicity (LAST). Bupivacaine tightly binds cardiac fast sodium channels, causing widening of the QRS, bradycardia, complete heart block, and refractory VF/Asystole. Neurological: LAST (CNS phase): Perioral numbness, metallic taste, tinnitus, leading to sudden violent seizures and coma. Tissue: Chondrotoxicity (can destroy cartilage if injected directly into a joint space continuously)." + }, + { + "label": "Key Interactions", + "value": "Additive toxicity with other local anaesthetics. You must calculate the TOTAL cumulative dose if the patient has had a Lidocaine block and a Bupivacaine epidural." + }, + { + "label": "Monitoring", + "value": "Aspiration before injecting every 3-5 mL is critical to ensure you are not in a blood vessel. Resuscitation equipment and Intralipid 20% MUST be immediately available in the room. Continuous **ECG** monitoring during large volume nerve blocks." + }, + { + "label": "Clinical Pearl", + "value": "If accidental IV injection occurs and the patient arrests, standard ALS (Adrenaline) often fails because the Bupivacaine is locked onto the cardiac receptors. You MUST administer Intralipid 20% IV. The lipid emulsion acts as a 'lipid sink', physically drawing the highly lipophilic Bupivacaine out of the heart tissue and saving the patient's life." + } + ] + }, + { + "slug": "capsaicin-cream", + "name": "Capsaicin cream", + "class": "Topical", + "subclass": "TRPV1 Agonist", + "category": "Analgesia - Topicals & Local", + "accent": "#be123c", + "tag": "TOPICAL", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "Apply QID", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "2-4 WEEKS", + "cls": "warn", + "flag": "" + }, + { + "label": "Burning", + "value": "INITIAL", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Wash Hands", + "value": "MANDATORY", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Active component of chili peppers. Radically depletes Substance P from sensory nerve endings. Highly effective for localized neuropathic pain and osteoarthritis, but burns fiercely upon initial application.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Apply a thin layer **QID**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The patient MUST wash their hands immediately after application to prevent catastrophic eye or mucosal burns.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Capsaicin cream is a topical analgesic for neuropathic and musculoskeletal pain, but requires consistent application for 2-4 weeks before benefit and causes initial burning sensation.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Dermatological", + "val": "HIGH — Severe localized burning, stinging, and erythema at the application site (especially during the first week).", + "tags": [] + }, + { + "key": "Mucosal", + "val": "CRITICAL — Excruciating pain if transferred to the eyes, nose, or genitals.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Post-Herpetic Neuralgia / Osteoarthritis", + "val": "**Topical** Rub into affected area 3 to 4 times daily. Must be used consistently; PRN use is completely ineffective.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zostrix (0.025%), Zostrix HP (0.075%), Qutenza (8% patch - Specialist only)", + "tags": [] + }, + { + "key": "Topical Routes", + "val": "Creams. High-potency clinical patches (used in pain clinics).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Post-herpetic neuralgia, localized osteoarthritis, diabetic neuropathy.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Excellent opioid-sparing adjunct for chronic, localized peripheral pain.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Broken skin, active wounds, application to face or mucous membranes.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — Limited systemic exposure is expected with topical use, but pregnancy/lactation use should still be checked with a clinician or pharmacist rather than displayed as unrestricted SAFE.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "Capsaicin topical use in pregnancy/lactation should prompt product-specific advice rather than an automatic contraindication or unrestricted safe label." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "NONE — Safe to use with all systemic medications.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Counsel that burning/stinging is common early, but avoid excessive application. Do not apply to cracked/broken skin, active shingles lesions, face, eyes, mucosa, or immediately before/after hot bathing; avoid tight bandaging.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Glove Trick", + "val": "Advise the patient to apply the cream using a disposable nitrile glove. Washing hands with soap does not easily remove the lipophilic capsaicin oil, and rubbing their eye 2 hours later will still cause a severe burn.", + "tags": [] + }, + { + "key": "The Warm Water Trap", + "val": "Taking a hot shower immediately after applying the cream will open the pores and cause an agonizing, fiery flare-up of the application site.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Agonizes the Transient Receptor Potential Vanilloid 1 (TRPV1) receptor. Initially causes massive release of Substance P (causing intense burning), followed by complete depletion of Substance P, rendering the nerve incapable of transmitting pain signals.", + "tags": [] + }, + { + "key": "Onset", + "val": "1-2 weeks of continuous use for pain relief. (Burning is immediate).", + "tags": [] + }, + { + "key": "Half-life", + "val": "Local action. Negligible systemic absorption.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: ZOSTRIX capsaicin Australian CMI/product source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "TRPV1 Agonist — Active component of chili peppers." + }, + { + "label": "Route / Formulation", + "value": "Creams. High-potency clinical patches (used in pain clinics). (Zostrix (0.025%), Zostrix HP (0.075%), Qutenza (8% patch - Specialist only))" + }, + { + "label": "Usual Dose & Max", + "value": "**Topical** Rub into affected area 3 to 4 times daily. Must be used consistently; PRN use is completely ineffective. Apply a thin layer **QID**." + }, + { + "label": "Best Uses", + "value": "Capsaicin cream is a topical analgesic for neuropathic and musculoskeletal pain, but requires consistent application for 2-4 weeks before benefit and causes initial burning sensation." + }, + { + "label": "Avoid / Cautions", + "value": "Avoid cracked/broken skin, active shingles lesions, face, eyes, mucosa, tight bandaging, and use immediately before/after hot bathing. Pregnancy/lactation: check product-specific advice rather than assuming unrestricted safety." + }, + { + "label": "Key Risks", + "value": "Dermatological: Severe localized burning, stinging, and erythema at the application site (especially during the first week). Mucosal: Excruciating pain if transferred to the eyes, nose, or genitals." + }, + { + "label": "Key Interactions", + "value": "NONE — Safe to use with all systemic medications." + }, + { + "label": "Monitoring", + "value": "Counsel patient: The burning sensation means it is working. It will fade after 3-5 days. If they stop using it because of the burn, the nerve resets and they have to start the painful process all over again." + }, + { + "label": "Clinical Pearl", + "value": "Advise the patient to apply the cream using a disposable nitrile glove. Washing hands with soap does not easily remove the lipophilic capsaicin oil, and rubbing their eye 2 hours later will still cause a severe burn." + } + ] + }, + { + "slug": "lidocaine-patch", + "name": "Lidocaine patch", + "class": "Topical", + "subclass": "Local Anaesthetic", + "category": "Analgesia - Topicals & Local", + "accent": "#be123c", + "tag": "TOPICAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "3 Patches/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "30-60 mins", + "cls": "", + "flag": "" + }, + { + "label": "12hr Off", + "value": "MANDATORY", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Systemic Abs.", + "value": "MINIMAL", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "5% Lidocaine infused hydrogel patch. Provides targeted, non-systemic blockade of damaged peripheral nerves. The absolute gold-standard topical agent for post-herpetic neuralgia (Shingles pain).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **3 patches applied simultaneously** per day.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The patch MUST be removed after 12 hours. The skin requires a 12-hour 'patch-free' period every day to prevent toxicity and skin breakdown.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Lidocaine patch is a topical local anaesthetic patch for localised neuropathic pain (post-herpetic neuralgia), but provides only local relief and should not be applied to broken skin or used with other local anaesthetics.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Dermatological", + "val": "MODERATE — Erythema, rash, pruritus at the application site (usually mild due to the cooling hydrogel).", + "tags": [] + }, + { + "key": "Systemic", + "val": "SAFE — Toxicity (seizures/arrhythmias) is virtually impossible unless patches are applied over massive areas of broken, bleeding skin.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Post-Herpetic Neuralgia", + "val": "**Topical** Apply 1 to 3 patches directly over the painful intact skin. Leave on for 12 hours, then remove for 12 hours (e.g., 8 AM to 8 PM). Patches can be cut to size.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Versatis 5%", + "tags": [] + }, + { + "key": "Topical Routes", + "val": "Adhesive hydrogel patches (700 mg lidocaine per patch).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) specifically for post-herpetic neuralgia.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Post-herpetic neuralgia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Localized neuropathic pain, severe localized rib fractures.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Outstanding opioid-sparing option for localized surface pain. Acts entirely locally with < 3% systemic absorption.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Do not apply over unhealed, active, blistering shingles lesions. Skin must be fully healed and intact.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Lidocaine patch pregnancy row is informational and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "LOW — Extremely safe to use alongside systemic neuropathic agents like Pregabalin or Amitriptyline (highly recommended synergistic combo).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure nursing staff actually remove the patch. Leaving it on for 24 hours causes severe skin maceration and reduced efficacy.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Scissor Rule", + "val": "Unlike Fentanyl or Buprenorphine patches (which contain a liquid drug reservoir that leaks if cut and kills the patient), the Versatis patch is a hydrogel matrix. It is perfectly safe and encouraged to cut it with scissors to fit the exact shape of the pain.", + "tags": [] + }, + { + "key": "The Cooling Effect", + "val": "The physical hydrogel patch provides a soothing, cooling physical barrier over hyper-sensitive skin (allodynia) where even a t-shirt touching the skin causes agony.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Slowly diffuses into the dermis. Blocks voltage-gated sodium channels on damaged, hyperactive pain receptors (A-delta and C fibers) just under the skin, without creating complete numbness (large A-beta sensory fibers are unaffected).", + "tags": [] + }, + { + "key": "Onset", + "val": "**Topical** 30-60 minutes.", + "tags": [] + }, + { + "key": "Duration", + "val": "12 hours of application provides relief that often outlasts the patch removal.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Negligible systemic absorption (< 3%).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: VERSATIS/lidocaine dermal patch Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Local Anaesthetic — 5% Lidocaine infused hydrogel patch." + }, + { + "label": "Route / Formulation", + "value": "Adhesive hydrogel patches (700 mg lidocaine per patch). (Versatis 5%)" + }, + { + "label": "Usual Dose & Max", + "value": "**Topical** Apply 1 to 3 patches directly over the painful intact skin. Leave on for 12 hours, then remove for 12 hours (e.g., 8 AM to 8 PM). Patches can be cut to size. Max **3 patches applied simultaneously** per day." + }, + { + "label": "Best Uses", + "value": "Lidocaine patch is a topical local anaesthetic patch for localised neuropathic pain (post-herpetic neuralgia), but provides only local relief and should not be applied to broken skin or used with other local anaesthetics." + }, + { + "label": "Avoid / Cautions", + "value": "Do not apply over unhealed, active, blistering shingles lesions. Skin must be fully healed and intact. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Dermatological: Erythema, rash, pruritus at the application site (usually mild due to the cooling hydrogel). Systemic: Toxicity (seizures/arrhythmias) is virtually impossible unless patches are applied over massive areas of broken, bleeding skin." + }, + { + "label": "Key Interactions", + "value": "Extremely safe to use alongside systemic neuropathic agents like Pregabalin or Amitriptyline (highly recommended synergistic combo)." + }, + { + "label": "Monitoring", + "value": "Ensure nursing staff actually remove the patch. Leaving it on for 24 hours causes severe skin maceration and reduced efficacy." + }, + { + "label": "Clinical Pearl", + "value": "Unlike Fentanyl or Buprenorphine patches (which contain a liquid drug reservoir that leaks if cut and kills the patient), the Versatis patch is a hydrogel matrix. It is perfectly safe and encouraged to cut it with scissors to fit the exact shape of the pain." + } + ] + }, + { + "slug": "lidocaine-viscous", + "name": "Lidocaine viscous", + "class": "Topical", + "subclass": "Local Anaesthetic", + "category": "Analgesia - Topicals & Local", + "accent": "#be123c", + "tag": "TOPICAL", + "schedule": "S3", + "stats": [ + { + "label": "Max Dose", + "value": "15 mL q3h", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "1-2 mins", + "cls": "", + "flag": "" + }, + { + "label": "Aspiration", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Seizures", + "value": "SYSTEMIC TOX", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Thick, gel-like topical amide local anaesthetic. Used to numb the oral cavity and upper GI tract for severe mucositis or instrumentation.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **15 mL every 3 hours** (Adults). Paediatric doses strictly weight-based.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Numbs the gag reflex. Patients MUST remain Nil By Mouth (NBM) for 60 minutes post-dose to prevent fatal aspiration of fluids into the lungs.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Lidocaine viscous is a topical local anaesthetic for oropharyngeal pain relief, but carries risk of systemic toxicity if swallowed excessively and can suppress the gag reflex increasing aspiration risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory", + "val": "CRITICAL — Loss of gag reflex leading to silent aspiration, pneumonia, or choking.", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Local Anaesthetic Systemic Toxicity (LAST) if swallowed in massive quantities: perioral numbness, tinnitus, metallic taste, leading to violent seizures and coma.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Arrhythmias and cardiovascular collapse (only in severe systemic toxicity).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Mucositis / Sore Throat", + "val": "**PO** 15 mL (2% solution) swished around the mouth and spat out, or swallowed if esophageal pain. Max q3h.", + "tags": [] + }, + { + "key": "Elderly / Paediatrics", + "val": "MANDATORY — Calculate dose strictly by weight (Max 3-4 mg/kg per dose) to prevent systemic toxicity.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Xylocaine Viscous 2%", + "tags": [] + }, + { + "key": "Topical Routes", + "val": "Oral viscous solution (20 mg/mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S2/S3).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Stomatitis, pharyngitis, post-tonsillectomy pain, preparation for endoscopy.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly effective for acute oral pain preventing eating/drinking, especially in chemotherapy-induced mucositis.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Patients with severely impaired swallowing mechanisms or absent gag reflex prior to administration. History of amide anaesthetic allergy (rare).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Lidocaine viscous pregnancy row is informational and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive toxicity with Class I antiarrhythmics (e.g., Flecainide) or other local anaesthetics (e.g., concurrent bupivacaine infusions).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Place a 'NIL BY MOUTH' sign above the bed for 60 minutes after every dose. No food, no water, no pills.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Spit vs Swallow", + "val": "For mouth ulcers (e.g., Hand, Foot, and Mouth), instruct the patient to swish and spit. Swallowing the viscous liquid provides no benefit to the mouth and only increases the risk of systemic absorption and seizure toxicity.", + "tags": [] + }, + { + "key": "The Tinnitus Warning", + "val": "If a patient using viscous lidocaine complains of ringing in the ears or a metallic taste, they are hitting toxic blood levels. Stop the drug instantly.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Blocks voltage-gated sodium channels in peripheral nerve endings, halting the generation and conduction of action potentials (pain signals).", + "tags": [] + }, + { + "key": "Onset", + "val": "**Topical** 1-2 minutes.", + "tags": [] + }, + { + "key": "Duration", + "val": "30-60 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1.5-2 hours (if swallowed and absorbed). First-pass metabolism heavily destroys swallowed drug, but mucosal absorption is high.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: XYLOCAINE VISCOUS/lidocaine Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Local Anaesthetic — Thick, gel-like topical amide local anaesthetic." + }, + { + "label": "Route / Formulation", + "value": "Oral viscous solution (20 mg/mL). (Xylocaine Viscous 2%)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 15 mL (2% solution) swished around the mouth and spat out, or swallowed if esophageal pain. Max q3h." + }, + { + "label": "Key Indication Doses", + "value": "Severe Mucositis / Sore Throat: **PO** 15 mL (2% solution) swished around the mouth and spat out, or swallowed if esophageal pain. Max q3h. Elderly / Paediatrics: Calculate dose strictly by weight (Max 3-4 mg/kg per dose) to prevent systemic toxicity." + }, + { + "label": "Best Uses", + "value": "Lidocaine viscous is a topical local anaesthetic for oropharyngeal pain relief, but carries risk of systemic toxicity if swallowed excessively and can suppress the gag reflex increasing aspiration risk." + }, + { + "label": "Avoid / Cautions", + "value": "Patients with severely impaired swallowing mechanisms or absent gag reflex prior to administration. History of amide anaesthetic allergy (rare). **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Respiratory: Loss of gag reflex leading to silent aspiration, pneumonia, or choking. Neurological: Local Anaesthetic Systemic Toxicity (LAST) if swallowed in massive quantities: perioral numbness, tinnitus, metallic taste, leading to violent seizures and coma. Cardiovascular: Arrhythmias and cardiovascular collapse (only in severe systemic toxicity)." + }, + { + "label": "Key Interactions", + "value": "Additive toxicity with Class I antiarrhythmics (e.g., Flecainide) or other local anaesthetics (e.g., concurrent bupivacaine infusions)." + }, + { + "label": "Monitoring", + "value": "Place a 'NIL BY MOUTH' sign above the bed for 60 minutes after every dose. No food, no water, no pills. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "For mouth ulcers (e.g., Hand, Foot, and Mouth), instruct the patient to swish and spit. Swallowing the viscous liquid provides no benefit to the mouth and only increases the risk of systemic absorption and seizure toxicity." + } + ] + }, + { + "slug": "lignocaine-lidocaine-sc", + "name": "Lignocaine/Lidocaine SC", + "class": "Local Anaesthetic", + "subclass": "Amide Anaesthetic", + "category": "Analgesia - Topicals & Local", + "accent": "#be123c", + "tag": "INJECTABLE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "3 mg/kg (Plain)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Max w/ Adren.", + "value": "7 mg/kg", + "cls": "good", + "flag": "" + }, + { + "label": "Onset", + "value": "1-2 mins", + "cls": "good", + "flag": "" + }, + { + "label": "LAST Risk", + "value": "SEIZURES", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The universal, rapid-acting, short-duration amide local anaesthetic. Used for suturing, minor procedures, and IV cannulation.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **3 mg/kg** (Plain solution) or **7 mg/kg** (Mixed with Adrenaline).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Exceeding the maximum weight-based dose will trigger Local Anaesthetic Systemic Toxicity (LAST), presenting as tinnitus and seizures.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Lignocaine/Lidocaine SC is the standard local anaesthetic for subcutaneous infiltration and minor procedures, but systemic toxicity (CNS then cardiac) occurs rapidly if maximum doses are exceeded or inadvertent IV injection occurs.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — LAST (Local Anaesthetic Systemic Toxicity). Begins with perioral numbness, ringing in the ears, and visual disturbances. Progresses rapidly to violent tonic-clonic seizures and coma.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Hypotension, bradycardia, arrhythmias (usually only seen after the CNS seizure phase, unlike bupivacaine which hits the heart first).", + "tags": [] + }, + { + "key": "Immunological", + "val": "SAFE — True IgE allergy to amide anaesthetics is exceptionally rare (allergies were common with old 'ester' anaesthetics like procaine).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Local Infiltration", + "val": "**SC** / **ID** 1% or 2% solution. Calculate safe volume based on patient weight. (e.g., for a 70kg adult, max plain 1% lidocaine is 21 mL).", + "tags": [] + }, + { + "key": "IV Regional Anaesthesia (Bier Block)", + "val": "**IV** 0.5% solution into a tourniquet-isolated limb.", + "tags": [] + }, + { + "key": "Antiarrhythmic (VT/VF)", + "val": "**IV** 1-1.5 mg/kg bolus (Acts as a Class Ib antiarrhythmic).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Xylocaine, Xylocaine with Adrenaline", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules/Vials (1%, 2%) for **SC**, **IM**, or **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital/Clinic supply. S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Local infiltration anaesthesia, regional nerve blocks, refractory ventricular tachycardia/fibrillation.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "The most commonly used local anaesthetic worldwide due to its near-instant onset and excellent safety profile at correct doses.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Heart block (2nd/3rd degree) for IV use. Severe hepatic failure (drug accumulates).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Adrenaline Prep", + "val": "CRITICAL — NEVER use Lidocaine + Adrenaline in 'end arteries' (fingers, toes, nose, penis, ears). The intense vasoconstriction will cause ischemic gangrene and tissue amputation.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Lignocaine/lidocaine injection pregnancy row is informational and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers and Amiodarone increase the risk of bradycardia and toxicity if lidocaine is used systemically.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Always draw back (aspirate) the syringe plunger before injecting to ensure the needle is not inside a blood vessel. Ask the patient to report ringing in their ears or a metallic taste immediately.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Math Trick", + "val": "A 1% solution contains 10 mg of drug per 1 mL. A 2% solution contains 20 mg per 1 mL. For a 70kg patient, Max plain dose is 210mg (which is 21 mL of 1% solution, or just 10.5 mL of 2% solution). Always calculate before drawing up.", + "tags": [] + }, + { + "key": "The Adrenaline Buffer", + "val": "Adding adrenaline (epinephrine) to the vial clamps the blood vessels shut. This prevents the lidocaine from washing away into the blood. It gives you a longer numbing effect, a bloodless surgical field, and allows you to safely use more than double the volume (7 mg/kg) without causing systemic toxicity.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to voltage-gated sodium channels from the inside of the cell membrane, preventing sodium influx and halting the propagation of the pain action potential.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 1-2 mins (Extremely fast).", + "tags": [] + }, + { + "key": "Duration", + "val": "1-2 h (Duration is doubled if formulated with adrenaline, which vasoconstricts and traps the drug at the site).", + "tags": [] + }, + { + "key": "Half-life", + "val": "1.5-2 hours. Metabolised by the liver (CYP1A2/3A4).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: XYLOCAINE/lidocaine injection Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Amide Anaesthetic — The universal, rapid-acting, short-duration amide local anaesthetic." + }, + { + "label": "Route / Formulation", + "value": "Ampoules/Vials (1%, 2%) for **SC**, **IM**, or **IV** use. (Xylocaine, Xylocaine with Adrenaline)" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** / **ID** 1% or 2% solution. Calculate safe volume based on patient weight. (e.g., for a 70kg adult, max plain 1% lidocaine is 21 mL)." + }, + { + "label": "Key Indication Doses", + "value": "Local Infiltration: **SC** / **ID** 1% or 2% solution. Calculate safe volume based on patient weight. (e.g., for a 70kg adult, max plain 1% lidocaine is 21 mL). IV Regional Anaesthesia (Bier Block): **IV** 0.5% solution into a tourniquet-isolated limb. Antiarrhythmic (VT/VF): **IV** 1-1.5 mg/kg bolus (Acts as a Class Ib antiarrhythmic)." + }, + { + "label": "Best Uses", + "value": "Lignocaine/Lidocaine SC is the standard local anaesthetic for subcutaneous infiltration and minor procedures, but systemic toxicity (CNS then cardiac) occurs rapidly if maximum doses are exceeded or inadvertent IV injection occurs." + }, + { + "label": "Avoid / Cautions", + "value": "Heart block (2nd/3rd degree) for IV use. Severe hepatic failure (drug accumulates). **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Neurological: LAST (Local Anaesthetic Systemic Toxicity). Begins with perioral numbness, ringing in the ears, and visual disturbances. Progresses rapidly to violent tonic-clonic seizures and coma. Cardiovascular: Hypotension, bradycardia, arrhythmias (usually only seen after the CNS seizure phase, unlike bupivacaine which hits the heart first). Immunological: True IgE allergy to amide anaesthetics is exceptionally rare (allergies were common with old 'ester' anaesthetics like procaine)." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers and Amiodarone increase the risk of bradycardia and toxicity if lidocaine is used systemically." + }, + { + "label": "Monitoring", + "value": "Always draw back (aspirate) the syringe plunger before injecting to ensure the needle is not inside a blood vessel. Ask the patient to report ringing in their ears or a metallic taste immediately." + }, + { + "label": "Clinical Pearl", + "value": "A 1% solution contains 10 mg of drug per 1 mL. A 2% solution contains 20 mg per 1 mL. For a 70kg patient, Max plain dose is 210mg (which is 21 mL of 1% solution, or just 10.5 mL of 2% solution). Always calculate before drawing up." + } + ] + }, + { + "slug": "amiodarone", + "name": "Amiodarone", + "class": "Antiarrhythmic", + "subclass": "Class III", + "category": "Cardiovascular - Antiarrhythmics", + "accent": "#0284c7", + "tag": "ANTIARRHYTHMIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1200 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "50 Days", + "cls": "warn", + "flag": "" + }, + { + "label": "Toxicity", + "value": "HIGH RISK", + "cls": "hi", + "flag": "" + }, + { + "label": "Thyroid", + "value": "MONITOR", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Incredibly potent, highly lipophilic antiarrhythmic. Extremely effective for chemical cardioversion and rhythm control, but riddled with severe, multi-organ toxicities.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1200 mg/day** (during acute loading phase only). Maintenance is 100-200 mg/day.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Amiodarone stays in the body for months after stopping. It interacts with almost everything and requires baseline tests for thyroid, lungs, and liver.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Amiodarone is the most effective antiarrhythmic for life-threatening arrhythmias, but causes devastating multi-organ toxicity (thyroid, lung, liver, eyes) requiring lifelong monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "HIGH — Hypothyroidism or severe Hyperthyroidism (contains 37% iodine by weight).", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Pulmonary fibrosis / interstitial pneumonitis (can be fatal).", + "tags": [] + }, + { + "key": "Hepatic", + "val": "MODERATE — Elevated transaminases, cirrhosis.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Ocular / Derm", + "val": "HIGH — Corneal microdeposits (halos/glare), photosensitivity, slate-grey skin discoloration ('smurf skin').", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Bradycardia, **QTc** prolongation, heart block.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Cardiac Arrest (VF/pVT)", + "val": "**IV** 300 mg bolus via central line (or large peripheral).", + "tags": [] + }, + { + "key": "Acute AF / Arrhythmia (IV)", + "val": "**IV** 300 mg over 1-2 hours via central line, followed by 900 mg over 24 hours.", + "tags": [] + }, + { + "key": "Oral Loading (AF)", + "val": "**PO** 400 mg **TDS** for 1 week, then 400 mg **OD** for 1 week, then maintenance.", + "tags": [] + }, + { + "key": "Maintenance", + "val": "**PO** 100-200 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Cordarone X, Aratac, Rythmodan", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (100 mg, 200 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (150 mg/3 mL) for **IV** infusion. Requires specific diluents (D5W).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Refractory VF/VT, atrial fibrillation (pharmacological cardioversion and maintenance).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The most effective antiarrhythmic available. The drug of choice for arrhythmias in patients with structural heart disease or HFrEF.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe bradycardia, sick sinus syndrome, iodine allergy, existing thyroid dysfunction.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. Causes neonatal goitre/hypothyroidism.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Amiodarone pregnancy row remains a source-backed high-risk/avoid prompt." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Potent inhibitor of CYP3A4, CYP2C9, and P-gp. Doubles the levels of Digoxin and Warfarin (halve their doses when starting amiodarone!). Increases statin toxicity.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers, CCBs, and other QTc prolonging drugs.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and 6-monthly **TFTs**, **LFTs**, and **U&E**.", + "tags": [] + }, + { + "key": "Imaging / Consults", + "val": "MANDATORY — Baseline CXR (for pulmonary fibrosis tracking). Annual optometry review.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor **ECG** for QTc prolongation and bradycardia.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Warfarin Halving", + "val": "When you start Amiodarone on a patient taking Warfarin, you MUST preemptively halve their Warfarin dose, or they will bleed. The INR will spike dramatically.", + "tags": [] + }, + { + "key": "The Phlebitis Risk", + "val": "Amiodarone is intensely irritating to veins. If run through a peripheral IV for more than an hour or two, it will cause severe chemical phlebitis. A central line is strongly preferred for 24-hour infusions.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Class III action (blocks K+ channels, prolonging action potential). Also exhibits Class I (Na+), Class II (beta-blocking), and Class IV (Ca2+) properties.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** Days to weeks. **IV** Minutes to hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "Weeks to months.", + "tags": [] + }, + { + "key": "Half-life", + "val": "20 to 100 Days (Highly lipophilic, saturates adipose tissue and organs).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - AMDARONE ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Class III — Incredibly potent, highly lipophilic antiarrhythmic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (100 mg, 200 mg). (Cordarone X, Aratac, Rythmodan)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 300 mg bolus via central line (or large peripheral). Max **1200 mg/day** (during acute loading phase only). Maintenance is 100-200 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Cardiac Arrest (VF/pVT): **IV** 300 mg bolus via central line (or large peripheral). Acute AF / Arrhythmia (IV): **IV** 300 mg over 1-2 hours via central line, followed by 900 mg over 24 hours. Oral Loading (AF): **PO** 400 mg **TDS** for 1 week, then 400 mg **OD** for 1 week, then maintenance. Maintenance: **PO** 100-200 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Amiodarone is the most effective antiarrhythmic for life-threatening arrhythmias, but causes devastating multi-organ toxicity (thyroid, lung, liver, eyes) requiring lifelong monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Severe bradycardia, sick sinus syndrome, iodine allergy, existing thyroid dysfunction. **Pregnancy** Category C. Causes neonatal goitre/hypothyroidism." + }, + { + "label": "Key Risks", + "value": "Endocrine: Hypothyroidism or severe Hyperthyroidism (contains 37% iodine by weight). Respiratory: Pulmonary fibrosis / interstitial pneumonitis (can be fatal). Hepatic: Elevated transaminases, cirrhosis. Ocular / Derm: Corneal microdeposits (halos/glare), photosensitivity, slate-grey skin discoloration ('smurf skin')." + }, + { + "label": "Key Interactions", + "value": "Potent inhibitor of CYP3A4, CYP2C9, and P-gp. Doubles the levels of Digoxin and Warfarin (halve their doses when starting amiodarone!). Increases statin toxicity. Beta-blockers, CCBs, and other QTc prolonging drugs." + }, + { + "label": "Monitoring", + "value": "Baseline and 6-monthly **TFTs**, **LFTs**, and **U&E**. Baseline CXR (for pulmonary fibrosis tracking). Annual optometry review. Monitor **ECG** for QTc prolongation and bradycardia." + }, + { + "label": "Clinical Pearl", + "value": "When you start Amiodarone on a patient taking Warfarin, you MUST preemptively halve their Warfarin dose, or they will bleed. The INR will spike dramatically." + } + ] + }, + { + "slug": "digoxin", + "name": "Digoxin", + "class": "Antiarrhythmic", + "subclass": "Cardiac Glycoside", + "category": "Cardiovascular - Antiarrhythmics", + "accent": "#0284c7", + "tag": "CARDIAC GLYCOSIDE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "500 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "36 h", + "cls": "", + "flag": "" + }, + { + "label": "Toxicity", + "value": "DOSE-DEP", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Target", + "value": "0.5-0.9 ng/mL", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ancient, narrow therapeutic index agent derived from the foxglove plant. Increases cardiac contractility while strongly slowing the AV node.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **500 mcg/day** (maintenance usually 62.5 - 250 mcg/day).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Hypokalemia makes the heart exquisitely sensitive to Digoxin, triggering fatal arrhythmias even at 'normal' blood levels.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Digoxin is a unique positive inotrope for heart failure and AF rate control, but has an extremely narrow therapeutic index requiring drug level monitoring to avoid fatal toxicity.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Arrhythmias (virtually any type, classically PVCs and bradycardia).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, vomiting, anorexia (often the very first sign of toxicity!).", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Confusion, visual disturbances (yellow-green halos around lights - xanthopsia).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "AF Rate Control (Loading)", + "val": "**PO** / **IV** 250-500 mcg. Repeat 250 mcg every 6 hours to a total loading dose of 750-1500 mcg.", + "tags": [] + }, + { + "key": "Maintenance", + "val": "**PO** 125-250 mcg **OD**.", + "tags": [] + }, + { + "key": "Elderly / Renal Impairment", + "val": "MANDATORY — Max 62.5 mcg **OD** or alternate days if **eGFR** is poor.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lanoxin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (62.5 mcg, 250 mcg). Oral Liquid.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (500 mcg/2 mL) for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Rate control in AF, symptomatic relief in HFrEF.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Add-on therapy when beta-blockers/CCBs fail or are contraindicated. Does NOT reduce mortality in heart failure, only reduces hospitalisations.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — WPW syndrome with AF, 2nd/3rd degree heart block, ventricular tachycardia.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Cleared renally. Toxicity is guaranteed if doses are not aggressively reduced in CKD.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Renal impairment requires digoxin dose reduction and close level/electrolyte monitoring." + } + }, + { + "key": "Electrolytes", + "val": "CRITICAL — Hypokalemia, hypomagnesemia, and hypercalcemia dramatically amplify toxicity.", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Amiodarone, Verapamil, and Macrolides double Digoxin levels via P-glycoprotein inhibition.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Diuretics (via potassium depletion).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Strict **U&E** monitoring. Maintain K+ > 4.0 mmol/L. Measure **TDM** (Digoxin levels) at least 6 hours post-dose (target 0.5-0.9 ng/mL for HF, up to 1.2 for AF).", + "tags": [] + }, + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Vomiting Warning", + "val": "If an elderly patient on Digoxin suddenly loses their appetite or starts vomiting, assume Digoxin toxicity until proven otherwise and withhold the drug.", + "tags": [] + }, + { + "key": "The Potassium Paradox", + "val": "Digoxin and Potassium bind to the same spot on the Na+/K+ pump. If K+ is low, there is no competition, and Digoxin binds too strongly, causing lethal toxicity.", + "tags": [] + }, + { + "key": "The Antidote", + "val": "In severe, life-threatening overdose (arrhythmias, hyperkalemia), the specific antidote is Digoxin Immune Fab (Digibind).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits the Na+/K+ ATPase pump in myocardial cells. This increases intracellular sodium, which in turn increases intracellular calcium (via the Na+/Ca2+ exchanger), increasing contractility (positive inotropy). Increases vagal tone, slowing the AV node (negative chronotropy).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours. **IV** 5-30 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "36-48 hours (Primarily renally excreted).", + "tags": [] + } + ] + }, + { + "title": "Special Populations", + "type": "spec", + "rows": [ + { + "key": "Elderly / Frail", + "val": "MANDATORY — The elderly are exquisitely sensitive to Digoxin toxicity. Renal clearance declines with age; lean body mass (the primary distribution volume) also decreases. Both effects dramatically reduce the 'safe' dose. Use 62.5 mcg **OD** or alternate-day dosing. Target serum Digoxin 0.5-0.9 nmol/L (lower than the old 'therapeutic range').", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Digoxin is 60-80% renally excreted. Any **eGFR** decline requires dose reduction. Reduce to 62.5 mcg **OD** if **eGFR** 20-50. Consider alternate-day dosing if **eGFR** < 20. Hypokalaemia (from diuretics) dramatically sensitises the myocardium to Digoxin toxicity.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category A. Digoxin crosses the placenta and can be used to treat fetal arrhythmias (SVT). However, requires specialist monitoring of both maternal and fetal levels.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - LANOXIN ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Cardiac Glycoside — Ancient, narrow therapeutic index agent derived from the foxglove plant." + }, + { + "label": "Route / Formulation", + "value": "Tablets (62.5 mcg, 250 mcg). Oral Liquid. (Lanoxin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** / **IV** 250-500 mcg. Repeat 250 mcg every 6 hours to a total loading dose of 750-1500 mcg. Max **500 mcg/day** (maintenance usually 62.5 - 250 mcg/day)." + }, + { + "label": "Key Indication Doses", + "value": "AF Rate Control (Loading): **PO** / **IV** 250-500 mcg. Repeat 250 mcg every 6 hours to a total loading dose of 750-1500 mcg. Maintenance: **PO** 125-250 mcg **OD**. Elderly / Renal Impairment: Max 62.5 mcg **OD** or alternate days if **eGFR** is poor." + }, + { + "label": "Best Uses", + "value": "Digoxin is a unique positive inotrope for heart failure and AF rate control, but has an extremely narrow therapeutic index requiring drug level monitoring to avoid fatal toxicity." + }, + { + "label": "Avoid / Cautions", + "value": "WPW syndrome with AF, 2nd/3rd degree heart block, ventricular tachycardia." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Arrhythmias (virtually any type, classically PVCs and bradycardia). Gastrointestinal: Nausea, vomiting, anorexia (often the very first sign of toxicity!). Neurological: Confusion, visual disturbances (yellow-green halos around lights - xanthopsia)." + }, + { + "label": "Key Interactions", + "value": "Amiodarone, Verapamil, and Macrolides double Digoxin levels via P-glycoprotein inhibition. Diuretics (via potassium depletion)." + }, + { + "label": "Monitoring", + "value": "Strict **U&E** monitoring. Maintain K+ > 4.0 mmol/L. Measure **TDM** (Digoxin levels) at least 6 hours post-dose (target 0.5-0.9 ng/mL for HF, up to 1.2 for AF). Baseline **ECG**." + }, + { + "label": "Clinical Pearl", + "value": "If an elderly patient on Digoxin suddenly loses their appetite or starts vomiting, assume Digoxin toxicity until proven otherwise and withhold the drug." + } + ] + }, + { + "slug": "flecainide", + "name": "Flecainide", + "class": "Antiarrhythmic", + "subclass": "Class Ic", + "category": "Cardiovascular - Antiarrhythmics", + "accent": "#0284c7", + "tag": "ANTIARRHYTHMIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12–27 h", + "cls": "", + "flag": "" + }, + { + "label": "Arrhythmia", + "value": "PROARRHYTHMIC", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent sodium-channel blocker used for rhythm control. Excellent for structurally normal hearts, but lethal if structural heart disease is present.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg/day** (given in divided doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never prescribe to a patient with a history of MI, ischaemic heart disease, or heart failure (CAST trial demonstrated increased mortality).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Flecainide is highly effective for pharmacological cardioversion of AF in structurally normal hearts, but is absolutely contraindicated in structural heart disease due to pro-arrhythmic risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Highly proarrhythmic (can cause fatal VT/VF), broadens QRS complex, negative inotrope (worsens HF).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Dizziness, visual disturbances (blurring), tremor, metallic taste.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "AF Rhythm Control", + "val": "Start **PO** 50 mg **BD**. Titrate slowly to Max 150 mg **BD** (300 mg/day).", + "tags": [] + }, + { + "key": "Pill-in-the-Pocket (AF)", + "val": "**PO** 200-300 mg as a single STAT dose to terminate acute AF (Requires prior safety testing in hospital).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce dose to max 100 mg/day if **eGFR** < 35.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Tambocor, Flecatab", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (50 mg, 100 mg). CR Capsules (200 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (150 mg/15 mL) for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention and termination of paroxysmal AF, SVT, and life-threatening VT.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line rhythm control agent for young, healthy patients without structural heart disease.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Structural heart disease (previous MI, HFrEF, LVH), 2nd/3rd degree AV block, bundle branch blocks.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Flecainide pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Beta-blockers/CCBs (additive negative inotropy and bradycardia).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (fluoxetine, amiodarone) significantly increase flecainide levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline and follow up **ECG**. QRS broadening > 25% requires immediate dose reduction or cessation.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **U&E** and **eGFR**. Measure **TDM** (Flecainide levels) in renal failure.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 1-to-1 Flutter Risk", + "val": "Flecainide can organize AF into Atrial Flutter. Because it slows atrial rates, the AV node might suddenly conduct every beat (1:1 conduction), causing the ventricular rate to jump to 200+ bpm. Always co-prescribe an AV nodal blocker (like Metoprolol) to prevent this.", + "tags": [] + }, + { + "key": "The CAST Trial Rule", + "val": "The Cardiac Arrhythmia Suppression Trial (CAST) proved that giving Class Ic agents to patients post-MI killed them. Always rule out structural heart disease with an ECHO before starting.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Class Ic antiarrhythmic. Markedly slows phase 0 depolarization via potent blockade of fast sodium channels in the His-Purkinje system and ventricles.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-3 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12-27 hours. Narrow therapeutic index.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TAMBOCOR ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Class Ic — Potent sodium-channel blocker used for rhythm control." + }, + { + "label": "Route / Formulation", + "value": "Tablets (50 mg, 100 mg). CR Capsules (200 mg). (Tambocor, Flecatab)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 50 mg **BD**. Titrate slowly to Max 150 mg **BD** (300 mg/day)." + }, + { + "label": "Key Indication Doses", + "value": "AF Rhythm Control: Start **PO** 50 mg **BD**. Titrate slowly to Max 150 mg **BD** (300 mg/day). Pill-in-the-Pocket (AF): **PO** 200-300 mg as a single STAT dose to terminate acute AF (Requires prior safety testing in hospital). Renal Impairment: Reduce dose to max 100 mg/day if **eGFR** < 35." + }, + { + "label": "Best Uses", + "value": "Flecainide is highly effective for pharmacological cardioversion of AF in structurally normal hearts, but is absolutely contraindicated in structural heart disease due to pro-arrhythmic risk." + }, + { + "label": "Avoid / Cautions", + "value": "Structural heart disease (previous MI, HFrEF, LVH), 2nd/3rd degree AV block, bundle branch blocks. **Pregnancy** Category B2." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Highly proarrhythmic (can cause fatal VT/VF), broadens QRS complex, negative inotrope (worsens HF). Neurological: Dizziness, visual disturbances (blurring), tremor, metallic taste." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers/CCBs (additive negative inotropy and bradycardia). **CYP2D6** inhibitors (fluoxetine, amiodarone) significantly increase flecainide levels." + }, + { + "label": "Monitoring", + "value": "Baseline and follow up **ECG**. QRS broadening > 25% requires immediate dose reduction or cessation. Routine **U&E** and **eGFR**. Measure **TDM** (Flecainide levels) in renal failure." + }, + { + "label": "Clinical Pearl", + "value": "Flecainide can organize AF into Atrial Flutter. Because it slows atrial rates, the AV node might suddenly conduct every beat (1:1 conduction), causing the ventricular rate to jump to 200+ bpm. Always co-prescribe an AV nodal blocker (like Metoprolol) to prevent this." + } + ] + }, + { + "slug": "sotalol", + "name": "Sotalol", + "class": "Antiarrhythmic", + "subclass": "Class III / Non-selective Beta Blocker", + "category": "Cardiovascular - Antiarrhythmics", + "accent": "#0284c7", + "tag": "CLASS III", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "320 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10–20 h", + "cls": "", + "flag": "" + }, + { + "label": "QTc Risk", + "value": "HIGH", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "MANDATORY", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Unique agent combining potent non-selective beta-blockade (Class II) with potassium channel blockade (Class III). Used for strict rhythm control in arrhythmias.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **320 mg/day** (given in divided doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "High risk of QT prolongation and Torsades de Pointes. Excreted 100% via kidneys; lethal if unadjusted in renal failure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Sotalol is a unique combined beta-blocker and Class III antiarrhythmic for AF and VT, but prolongs QTc and requires ECG monitoring with dose changes due to risk of Torsades de Pointes.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Dose-dependent QTc prolongation, Torsades de Pointes, profound bradycardia, heart failure exacerbation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Respiratory", + "val": "HIGH — Bronchospasm (non-selective beta blocker).", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Fatigue, dizziness, sleep disturbances.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "AF Rhythm Control", + "val": "Start **PO** 80 mg **BD**. Titrate slowly under ECG guidance to Max 160 mg **BD** (320 mg/day).", + "tags": [] + }, + { + "key": "Ventricular Arrhythmias", + "val": "**PO** 80-160 mg **BD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — **eGFR** 30-60: Give dose **OD**. **eGFR** 10-30: Give dose every 48 hours. **eGFR** <10: CONTRAINDICATED.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Sotacor, Solavert", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (80 mg, 160 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule for **IV** use (Rare, highly specialised).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance of sinus rhythm in AF/AFL, suppression of VT.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Used when a patient needs both rate and rhythm control, but requires perfect renal function and QT monitoring.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe asthma, baseline **QTc** > 450 ms, uncorrected hypokalemia, 2nd/3rd degree heart block, severe renal failure.", + "tags": [], + "patient": { + "factors": ["renal", "qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 15 + }, + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Sotalol pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Any other QT prolonging drugs (e.g., Macrolides, SSRIs, Antipsychotics) risk fatal arrhythmias.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Non-DHP CCBs (Verapamil) risk asystole.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline and ongoing **ECG**. Cease immediately if **QTc** > 500 ms. Do not start until baseline QTc is confirmed normal.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Laboratory", + "val": "MANDATORY — Strict baseline and regular **U&E** (K+ and Mg2+ MUST be kept in the high-normal range) and **eGFR**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Reverse Use-Dependence", + "val": "Sotalol has a dangerous paradox: its QT-prolonging effect is strongest when the heart rate is SLOW. This makes bradycardic patients exquisitely vulnerable to Torsades de Pointes.", + "tags": [] + }, + { + "key": "Not for Rate Control", + "val": "Do NOT use Sotalol purely for AF rate control. Standard beta-blockers (Metoprolol/Bisoprolol) are much safer. Sotalol is only for keeping patients in sinus rhythm (rhythm control).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Non-selective beta-1 and beta-2 blocker (slows AV node). Prolongs the action potential duration and refractory period via K+ channel blockade.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10-20 hours. 100% renally excreted, completely unmetabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - SOTACOR ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Class III / Non-selective Beta Blocker — Unique agent combining potent non-selective beta-blockade (Class II) with potassium channel blockade (Class III)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (80 mg, 160 mg). (Sotacor, Solavert)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 80 mg **BD**. Titrate slowly under ECG guidance to Max 160 mg **BD** (320 mg/day)." + }, + { + "label": "Key Indication Doses", + "value": "AF Rhythm Control: Start **PO** 80 mg **BD**. Titrate slowly under ECG guidance to Max 160 mg **BD** (320 mg/day). Ventricular Arrhythmias: **PO** 80-160 mg **BD**. Renal Impairment: **eGFR** 30-60: Give dose **OD**. **eGFR** 10-30: Give dose every 48 hours. **eGFR** <10: CONTRAINDICATED." + }, + { + "label": "Best Uses", + "value": "Sotalol is a unique combined beta-blocker and Class III antiarrhythmic for AF and VT, but prolongs QTc and requires ECG monitoring with dose changes due to risk of Torsades de Pointes." + }, + { + "label": "Avoid / Cautions", + "value": "Severe asthma, baseline **QTc** > 450 ms, uncorrected hypokalemia, 2nd/3rd degree heart block, severe renal failure. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Dose-dependent QTc prolongation, Torsades de Pointes, profound bradycardia, heart failure exacerbation. Respiratory: Bronchospasm (non-selective beta blocker). Neurological: Fatigue, dizziness, sleep disturbances." + }, + { + "label": "Key Interactions", + "value": "Any other QT prolonging drugs (e.g., Macrolides, SSRIs, Antipsychotics) risk fatal arrhythmias. Non-DHP CCBs (Verapamil) risk asystole." + }, + { + "label": "Monitoring", + "value": "Baseline and ongoing **ECG**. Cease immediately if **QTc** > 500 ms. Do not start until baseline QTc is confirmed normal. Strict baseline and regular **U&E** (K+ and Mg2+ MUST be kept in the high-normal range) and **eGFR**." + }, + { + "label": "Clinical Pearl", + "value": "Sotalol has a dangerous paradox: its QT-prolonging effect is strongest when the heart rate is SLOW. This makes bradycardic patients exquisitely vulnerable to Torsades de Pointes." + } + ] + }, + { + "slug": "glyceryl-trinitrate-gtn", + "name": "Glyceryl trinitrate (GTN)", + "class": "Antianginal", + "subclass": "Nitrate", + "category": "Cardiovascular - Antiarrhythmics & Antianginals", + "accent": "#0284c7", + "tag": "NITRATE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Variable", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1–4 mins", + "cls": "warn", + "flag": "" + }, + { + "label": "Headache", + "value": "COMMON", + "cls": "warn", + "flag": "" + }, + { + "label": "Tolerance", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent, extremely fast-acting venodilator. The absolute gold standard for acute termination of angina and reduction of preload in acute pulmonary oedema (APO).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max varies entirely by formulation and BP response. Sublingual: Max 2 sprays/tablets per 15 mins.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Causes profound, sudden hypotension. Patients MUST sit down before using the spray.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Glyceryl trinitrate (GTN) is the first-line sublingual treatment for acute angina and chest pain, but causes significant headache and hypotension, and must never be combined with PDE5 inhibitors.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Severe orthostatic hypotension, reflex tachycardia, syncope.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — 'Nitrate Headache' (throbbing, severe, caused by meningeal vasodilation).", + "tags": [] + }, + { + "key": "Other", + "val": "HIGH — Nitrate tolerance (loss of efficacy if used continuously without a break).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Angina (Sublingual)", + "val": "**SL** 300-600 mcg (1/2 to 1 tablet) OR 1-2 sprays under tongue. Wait 5 mins. If pain persists, call ambulance. Max 3 doses/15 mins.", + "tags": [] + }, + { + "key": "Angina Prophylaxis (Patch)", + "val": "Apply 5-10 mg patch **Topical** daily. Remove patch for 10-12 hours overnight to prevent tolerance.", + "tags": [] + }, + { + "key": "Acute Pulmonary Oedema / HTN Crisis", + "val": "**IV** Infusion start at 5-10 mcg/min. Titrate rapidly up to 200 mcg/min based on response.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nitrolingual, Lycinate, Transiderm-Nitro, Minitran", + "tags": [] + }, + { + "key": "Routes", + "val": "Sublingual pump spray (400 mcg/dose). SL tablets (600 mcg). Transdermal patches. IV ampoules.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Spray/Tabs are Pharmacy Medicine (S3). Patches/IV are S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute angina, angina prophylaxis, acute pulmonary oedema, heart failure.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line for acute cardiac ischaemic chest pain. Powerful preload reducer in the ED/ICU for APO.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — SBP < 90 mmHg, Right Ventricular (Inferior) MI (preload dependent), severe aortic stenosis, raised intracranial pressure.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Glyceryl trinitrate (GTN) pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — PDE-5 Inhibitors (Sildenafil/Viagra). Co-administration within 24 hours causes catastrophic, refractory, and fatal hypotension. Check before giving in ED.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Alcohol, other antihypertensives (additive drops in BP).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure patient is sitting. Monitor **BP** and **HR** continuously if giving **IV** or repeatedly for angina.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Right Ventricle Trap", + "val": "Never give GTN to a patient with an Inferior STEMI (Right Ventricular involvement). The RV requires high preload to push blood into the lungs. GTN removes preload and drops cardiac output to zero.", + "tags": [] + }, + { + "key": "The Patch Holiday", + "val": "Vessels run out of the sulfhydryl groups needed to convert GTN to Nitric Oxide. You MUST prescribe a 'patch-off' period of 10-12 hours every night, or the patch will stop working entirely.", + "tags": [] + }, + { + "key": "Tablet Storage", + "val": "SL tablets degrade rapidly. They must be discarded 8 weeks after the bottle is opened. The spray does not expire as quickly and is safer for carry.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Metabolised in vascular smooth muscle to Nitric Oxide (NO). NO activates cGMP, causing powerful venodilation (pooling blood in veins) and mild coronary dilation. Reduces preload and cardiac oxygen demand.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SL** 1-3 mins. **IV** Immediate. **Topical** 30-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "**SL** 30 mins. **Topical** 12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-4 minutes (Rapid hepatic and blood metabolism).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - NITROLINGUAL/DBL GTN ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Nitrate — Potent, extremely fast-acting venodilator." + }, + { + "label": "Route / Formulation", + "value": "Sublingual pump spray (400 mcg/dose). SL tablets (600 mcg). Transdermal patches. IV ampoules. (Nitrolingual, Lycinate, Transiderm-Nitro, Minitran)" + }, + { + "label": "Usual Dose & Max", + "value": "**SL** 300-600 mcg (1/2 to 1 tablet) OR 1-2 sprays under tongue. Wait 5 mins. If pain persists, call ambulance. Max 3 doses/15 mins." + }, + { + "label": "Key Indication Doses", + "value": "Acute Angina (Sublingual): **SL** 300-600 mcg (1/2 to 1 tablet) OR 1-2 sprays under tongue. Wait 5 mins. If pain persists, call ambulance. Max 3 doses/15 mins. Angina Prophylaxis (Patch): Apply 5-10 mg patch **Topical** daily. Remove patch for 10-12 hours overnight to prevent tolerance. Acute Pulmonary Oedema / HTN Crisis: **IV** Infusion start at 5-10 mcg/min. Titrate rapidly up to 200 mcg/min based on response." + }, + { + "label": "Best Uses", + "value": "Glyceryl trinitrate (GTN) is the first-line sublingual treatment for acute angina and chest pain, but causes significant headache and hypotension, and must never be combined with PDE5 inhibitors." + }, + { + "label": "Avoid / Cautions", + "value": "SBP < 90 mmHg, Right Ventricular (Inferior) MI (preload dependent), severe aortic stenosis, raised intracranial pressure. **Pregnancy** Category B2." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Severe orthostatic hypotension, reflex tachycardia, syncope. Neurological: 'Nitrate Headache' (throbbing, severe, caused by meningeal vasodilation). Other: Nitrate tolerance (loss of efficacy if used continuously without a break)." + }, + { + "label": "Key Interactions", + "value": "PDE-5 Inhibitors (Sildenafil/Viagra). Co-administration within 24 hours causes catastrophic, refractory, and fatal hypotension. Check before giving in ED. Alcohol, other antihypertensives (additive drops in BP)." + }, + { + "label": "Monitoring", + "value": "Ensure patient is sitting. Monitor **BP** and **HR** continuously if giving **IV** or repeatedly for angina." + }, + { + "label": "Clinical Pearl", + "value": "Never give GTN to a patient with an Inferior STEMI (Right Ventricular involvement). The RV requires high preload to push blood into the lungs. GTN removes preload and drops cardiac output to zero." + } + ] + }, + { + "slug": "amlodipine", + "name": "Amlodipine", + "class": "Antihypertensive", + "subclass": "DHP Calcium Channel Blocker", + "category": "Cardiovascular - Antihypertensives", + "accent": "#0284c7", + "tag": "DHP-CCB", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "30-50 h", + "cls": "", + "flag": "" + }, + { + "label": "Peripheral Edema", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Grapefruit", + "value": "SAFE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Dihydropyridine (DHP) Calcium Channel Blocker. Pure, extremely potent peripheral vasodilator. Excellent for lowering blood pressure but notorious for causing swollen ankles.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Unlike Verapamil/Diltiazem, Amlodipine has virtually zero effect on the heart rate or AV node. It strictly relaxes blood vessels.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Amlodipine is a first-line antihypertensive with no monitoring burden and safe in most populations, but peripheral oedema is common and dose-limiting.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Severe peripheral edema (swollen, pitting ankles/legs). Extremely common at 10mg. HIGH — Flushing, palpitations, hypotension.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Gingival hyperplasia (swollen gums).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertension / Angina", + "val": "Start **PO** 5 mg **OD**. Titrate to Max 10 mg **OD**.", + "tags": [] + }, + { + "key": "Elderly / Hepatic Impairment", + "val": "MANDATORY — Start at 2.5 mg **OD**. Clearance is severely delayed in liver disease.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Norvasc", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5, 10 mg). Often combined with Perindopril (Reaptan) or Valsartan (Exforge).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension, chronic stable angina, Prinzmetal's (vasospastic) angina.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line antihypertensive, especially in elderly and Afro-Caribbean patients who respond poorly to ACE inhibitors.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe hypotension, cardiogenic shock, severe aortic stenosis (vasodilation will drop coronary perfusion fatally).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Amlodipine pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP3A4** inhibitors (Clarithromycin, Ketoconazole) spike Amlodipine levels, worsening edema and hypotension.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "SAFE — Unlike Felodipine, Amlodipine does NOT interact significantly with Grapefruit juice.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Check **BP**. Inspect the patient's ankles for severe pitting edema before escalating from 5mg to 10mg.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Diuretic Myth", + "val": "If a patient on Amlodipine develops swollen ankles, prescribing Frusemide (a diuretic) will NOT fix it. The edema is caused by capillary hydrostatic pressure leaking fluid into the tissues, not by whole-body fluid overload. You must either halve the Amlodipine dose or add an ACEi (which dilates the venules to drain the fluid).", + "tags": [] + }, + { + "key": "The Gingival Swell", + "val": "If a patient presents with massive, overgrown gums bleeding over their teeth, check their med list. Amlodipine, Phenytoin, and Cyclosporin are the classic triad for gingival hyperplasia.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Blocks L-type voltage-gated calcium channels in vascular smooth muscle. Prevents calcium influx, halting muscle contraction, leading to massive, sustained vasodilation of peripheral and coronary arteries.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 6-12 hours (Slow onset, zero reflex tachycardia).", + "tags": [] + }, + { + "key": "Half-life", + "val": "30-50 hours (Allows perfect once-daily dosing and forgives missed doses). Metabolised by CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: NORDIP/amlodipine Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "DHP Calcium Channel Blocker — Dihydropyridine (DHP) Calcium Channel Blocker." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5, 10 mg). Often combined with Perindopril (Reaptan) or Valsartan (Exforge). (Norvasc)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 5 mg **OD**. Titrate to Max 10 mg **OD**." + }, + { + "label": "Key Indication Doses", + "value": "Hypertension / Angina: Start **PO** 5 mg **OD**. Titrate to Max 10 mg **OD**. Elderly / Hepatic Impairment: Start at 2.5 mg **OD**. Clearance is severely delayed in liver disease." + }, + { + "label": "Best Uses", + "value": "Amlodipine is a first-line antihypertensive with no monitoring burden and safe in most populations, but peripheral oedema is common and dose-limiting." + }, + { + "label": "Avoid / Cautions", + "value": "Severe hypotension, cardiogenic shock, severe aortic stenosis (vasodilation will drop coronary perfusion fatally). **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Severe peripheral edema (swollen, pitting ankles/legs). Extremely common at 10mg. HIGH — Flushing, palpitations, hypotension. Gastrointestinal: Gingival hyperplasia (swollen gums)." + }, + { + "label": "Key Interactions", + "value": "**CYP3A4** inhibitors (Clarithromycin, Ketoconazole) spike Amlodipine levels, worsening edema and hypotension. Unlike Felodipine, Amlodipine does NOT interact significantly with Grapefruit juice." + }, + { + "label": "Monitoring", + "value": "Check **BP**. Inspect the patient's ankles for severe pitting edema before escalating from 5mg to 10mg." + }, + { + "label": "Clinical Pearl", + "value": "If a patient on Amlodipine develops swollen ankles, prescribing Frusemide (a diuretic) will NOT fix it. The edema is caused by capillary hydrostatic pressure leaking fluid into the tissues, not by whole-body fluid overload. You must either halve the Amlodipine dose or add an ACEi (which dilates the venules to drain the fluid)." + } + ] + }, + { + "slug": "candesartan", + "name": "Candesartan", + "class": "Antihypertensive", + "subclass": "ARB", + "category": "Cardiovascular - Antihypertensives", + "accent": "#0284c7", + "tag": "ARB", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "32 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "9 h", + "cls": "", + "flag": "" + }, + { + "label": "Dry Cough", + "value": "SAFE", + "cls": "good", + "flag": "" + }, + { + "label": "Hyperkalemia", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Angiotensin II Receptor Blocker (ARB). The direct alternative to ACE inhibitors. Provides identical cardiovascular and renal protection without causing the bradykinin-mediated dry cough.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **32 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Carries the exact same risk of hyperkalemia, renal failure (Triple Whammy), and fetal toxicity as ACE inhibitors.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Candesartan is the ideal ACE inhibitor substitute (no cough) with unique migraine prophylaxis evidence, but carries identical renal and pregnancy risks to ACEis.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal", + "val": "HIGH — Hyperkalemia, AKI in volume-depleted patients.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Orthostatic hypotension, dizziness.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "SAFE — Incidence of dry cough is equivalent to placebo.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertension", + "val": "Start **PO** 8-16 mg **OD**. Max 32 mg/day.", + "tags": [] + }, + { + "key": "Heart Failure (HFrEF)", + "val": "Start **PO** 4 mg **OD**. Titrate doubling the dose every 2 weeks to target 32 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Start at 4 mg **OD** if **eGFR** < 30. Monitor K+.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Atacand", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (4, 8, 16, 32 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension, Heart Failure, Diabetic nephropathy.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line substitute for patients who develop an ACE-inhibitor cough. Identical efficacy in heart failure.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Bilateral renal artery stenosis, severe hepatic impairment/cholestasis.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Causes fetal renal failure/death.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Triple Whammy", + "val": "CRITICAL — ARB + Diuretic + NSAID (Guaranteed AKI).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive hyperkalemia with Spironolactone or Trimethoprim.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **U&E** 1-2 weeks post-initiation.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Check **BP**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Migraine Shield", + "val": "Candesartan has strong, unique evidence for Migraine Prophylaxis (off-label). It is frequently prescribed by neurologists to prevent chronic migraines while simultaneously treating the patient's blood pressure.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Highly selective, competitive antagonist of the Angiotensin II Type 1 (AT1) receptor. Blocks the vasoconstrictive and aldosterone-secreting effects of Angiotensin II. Does not inhibit kinase II (so bradykinin does not accumulate).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2-3 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "9 hours (Prodrug converted to active candesartan in the gut wall).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ATACAND/candesartan Australian ARTG-CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "ARB — Angiotensin II Receptor Blocker (ARB)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (4, 8, 16, 32 mg). (Atacand)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 8-16 mg **OD**. Max 32 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Hypertension: Start **PO** 8-16 mg **OD**. Max 32 mg/day. Heart Failure (HFrEF): Start **PO** 4 mg **OD**. Titrate doubling the dose every 2 weeks to target 32 mg **OD**. Renal Impairment: Start at 4 mg **OD** if **eGFR** < 30. Monitor K+." + }, + { + "label": "Best Uses", + "value": "Candesartan is the ideal ACE inhibitor substitute (no cough) with unique migraine prophylaxis evidence, but carries identical renal and pregnancy risks to ACEis." + }, + { + "label": "Avoid / Cautions", + "value": "Bilateral renal artery stenosis, severe hepatic impairment/cholestasis. **Pregnancy** Category D. Causes fetal renal failure/death." + }, + { + "label": "Key Risks", + "value": "Renal: Hyperkalemia, AKI in volume-depleted patients. Cardiovascular: Orthostatic hypotension, dizziness. Respiratory: Incidence of dry cough is equivalent to placebo." + }, + { + "label": "Key Interactions", + "value": "ARB + Diuretic + NSAID (Guaranteed AKI). Additive hyperkalemia with Spironolactone or Trimethoprim." + }, + { + "label": "Monitoring", + "value": "Check **U&E** 1-2 weeks post-initiation. Check **BP**." + }, + { + "label": "Clinical Pearl", + "value": "Candesartan has strong, unique evidence for Migraine Prophylaxis (off-label). It is frequently prescribed by neurologists to prevent chronic migraines while simultaneously treating the patient's blood pressure." + } + ] + }, + { + "slug": "diltiazem", + "name": "Diltiazem", + "class": "Antihypertensive", + "subclass": "Non-DHP CCB", + "category": "Cardiovascular - Antihypertensives", + "accent": "#0284c7", + "tag": "NON-DHP CCB", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "360 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4–9 h", + "cls": "", + "flag": "" + }, + { + "label": "Bradycardia", + "value": "RISK", + "cls": "warn", + "flag": "" + }, + { + "label": "Heart Block", + "value": "AVOID", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Non-dihydropyridine CCB. A 'middle ground' between Amlodipine and Verapamil, offering both coronary vasodilation and mild AV nodal slowing.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **360 mg/day** (usually extended-release).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Excellent for angina and rate control in AF, but carries the same dangerous interaction with beta-blockers as Verapamil.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Diltiazem is a versatile non-DHP CCB for rate control and angina with fewer GI side effects than Verapamil, but must not be combined with beta-blockers and inhibits CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Bradycardia, AV block, worsening of HFrEF. MODERATE — Peripheral oedema (less than amlodipine).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Constipation (much less severe than Verapamil).", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Dizziness, headache.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Angina / Hypertension", + "val": "**PO** 180-240 mg CD/XR **OD**. Titrate up to Max **360 mg/day**.", + "tags": [] + }, + { + "key": "AF Rate Control", + "val": "**PO** 180-360 mg CD/XR **OD**.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Start at **PO** 120 mg CD **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Cardizem CD, Vasocardol CD, Dilzem", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Controlled Delivery (CD) capsules (120 mg, 180 mg, 240 mg, 360 mg). Do not chew.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension, chronic stable angina, AF rate control.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Preferred over Verapamil when less negative inotropy is desired, but rate control is still required.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Left ventricular failure (HFrEF), 2nd/3rd degree heart block, sick sinus syndrome.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "CAUTION — Extensively metabolised by the liver. Dose reduction required in severe **Hepatic** impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "hepatic": ["severe"] + }, + "note": "Diltiazem hepatic impairment row should prompt dose review rather than automatic contraindication." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Diltiazem pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Beta-blockers. High risk of complete heart block and severe bradycardia if combined.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Moderate **CYP3A4** inhibitor. Markedly increases statin levels (myopathy) and increases Digoxin concentrations by ~20%.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline and routine **ECG** to assess PR interval. Monitor **HR** and **BP**.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **LFTs** periodically. No specific **U&E** shifts expected.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The HFrEF Rule", + "val": "Like Verapamil, Diltiazem reduces cardiac contractility. It must be avoided in patients with heart failure with reduced ejection fraction (HFrEF).", + "tags": [] + }, + { + "key": "Statin Toxicity", + "val": "If a patient is admitted with rhabdomyolysis or severe myalgia, check if Diltiazem was recently added to their Atorvastatin/Simvastatin regimen.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits calcium influx across cell membranes. Relaxes coronary and peripheral blood vessels, and slows AV node conduction.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2-3 hours (CD formulation).", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h (CD formulation).", + "tags": [] + }, + { + "key": "Half-life", + "val": "4-9 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: CARDIZEM CD/diltiazem Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Non-DHP CCB — Non-dihydropyridine CCB." + }, + { + "label": "Route / Formulation", + "value": "Controlled Delivery (CD) capsules (120 mg, 180 mg, 240 mg, 360 mg). Do not chew. (Cardizem CD, Vasocardol CD, Dilzem)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 180-240 mg CD/XR **OD**. Titrate up to Max **360 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Angina / Hypertension: **PO** 180-240 mg CD/XR **OD**. Titrate up to Max **360 mg/day**. AF Rate Control: **PO** 180-360 mg CD/XR **OD**. Elderly / Frail: Start at **PO** 120 mg CD **OD**." + }, + { + "label": "Best Uses", + "value": "Diltiazem is a versatile non-DHP CCB for rate control and angina with fewer GI side effects than Verapamil, but must not be combined with beta-blockers and inhibits CYP3A4." + }, + { + "label": "Avoid / Cautions", + "value": "Left ventricular failure (HFrEF), 2nd/3rd degree heart block, sick sinus syndrome. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Bradycardia, AV block, worsening of HFrEF. MODERATE — Peripheral oedema (less than amlodipine). Gastrointestinal: Constipation (much less severe than Verapamil). Neurological: Dizziness, headache." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers. High risk of complete heart block and severe bradycardia if combined. Moderate **CYP3A4** inhibitor. Markedly increases statin levels (myopathy) and increases Digoxin concentrations by ~20%." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **ECG** to assess PR interval. Monitor **HR** and **BP**. Check **LFTs** periodically. No specific **U&E** shifts expected." + }, + { + "label": "Clinical Pearl", + "value": "Like Verapamil, Diltiazem reduces cardiac contractility. It must be avoided in patients with heart failure with reduced ejection fraction (HFrEF)." + } + ] + }, + { + "slug": "felodipine", + "name": "Felodipine", + "class": "Antihypertensive", + "subclass": "Calcium Channel Blocker", + "category": "Cardiovascular - Antihypertensives", + "accent": "#0284c7", + "tag": "CCB", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "11–16 h", + "cls": "", + "flag": "" + }, + { + "label": "Edema", + "value": "COMMON", + "cls": "warn", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "NOT REQ.", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly vascular-selective dihydropyridine CCB. Potent peripheral vasodilator with no negative inotropic effects on the heart.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day**", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be swallowed whole (extended-release). Avoid grapefruit juice entirely as it dramatically spikes plasma levels.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Felodipine is a potent vascular-selective CCB for resistant hypertension, but must be swallowed whole and grapefruit juice is absolutely contraindicated.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Peripheral oedema (non-hydrostatic, worse at high doses). MODERATE — Flushing, reflex tachycardia.", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Headache (usually transient upon initiation).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Gingival hyperplasia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertension", + "val": "**PO** 2.5–5 mg **OD**. May increase gradually to Max **20 mg/day**.", + "tags": [] + }, + { + "key": "Elderly / Hepatic Impaired", + "val": "Start at **PO** 2.5 mg **OD**. Target 5-10 mg/day. Max **10 mg/day** in severe hepatic impairment.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Plendil ER, Felodur ER", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Extended-release tablets (2.5 mg, 5 mg, 10 mg). Do not crush.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Second-line or add-on antihypertensive. Useful in isolated systolic hypertension in the elderly.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Uncompensated heart failure, acute MI (within 1 month), severe aortic stenosis.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "CAUTION — Reduced clearance in **Hepatic** impairment; max dose typically 10 mg.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "hepatic": ["severe"] + }, + "note": "Felodipine hepatic impairment row should prompt dose review rather than automatic contraindication." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C. Avoid unless the clinical benefit clearly outweighs fetal risk.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Felodipine pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — **CYP3A4** inhibitors (macrolides, azoles, grapefruit juice) vastly increase felodipine levels causing severe hypotension.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CAUTION — Inducers (carbamazepine, phenytoin) will drastically reduce efficacy.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **BP** and assess for peripheral oedema.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **U&E** monitoring not required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Grapefruit Rule", + "val": "Grapefruit irreversibly blocks intestinal CYP3A4 for up to 72 hours. One glass can double felodipine bioavailability, leading to shock.", + "tags": [] + }, + { + "key": "Oedema Fix", + "val": "Diuretics (like frusemide) do not fix CCB-induced oedema. Adding an ACEi/ARB or dose reduction is required.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Blocks L-type calcium channels in vascular smooth muscle, reducing peripheral vascular resistance.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2-5 hours (extended release).", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "11-16 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: PLENDIL ER/felodipine Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Calcium Channel Blocker — Highly vascular-selective dihydropyridine CCB." + }, + { + "label": "Route / Formulation", + "value": "Extended-release tablets (2.5 mg, 5 mg, 10 mg). Do not crush. (Plendil ER, Felodur ER)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 2.5–5 mg **OD**. May increase gradually to Max **20 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Hypertension: **PO** 2.5–5 mg **OD**. May increase gradually to Max **20 mg/day**. Elderly / Hepatic Impaired: Start at **PO** 2.5 mg **OD**. Target 5-10 mg/day. Max **10 mg/day** in severe hepatic impairment." + }, + { + "label": "Best Uses", + "value": "Felodipine is a potent vascular-selective CCB for resistant hypertension, but must be swallowed whole and grapefruit juice is absolutely contraindicated." + }, + { + "label": "Avoid / Cautions", + "value": "Uncompensated heart failure, acute MI (within 1 month), severe aortic stenosis. **Pregnancy** Category C. Do not use." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Peripheral oedema (non-hydrostatic, worse at high doses). MODERATE — Flushing, reflex tachycardia. Neurological: Headache (usually transient upon initiation). Gastrointestinal: Gingival hyperplasia." + }, + { + "label": "Key Interactions", + "value": "**CYP3A4** inhibitors (macrolides, azoles, grapefruit juice) vastly increase felodipine levels causing severe hypotension. Inducers (carbamazepine, phenytoin) will drastically reduce efficacy." + }, + { + "label": "Monitoring", + "value": "Monitor **BP** and assess for peripheral oedema. Routine **U&E** monitoring not required." + }, + { + "label": "Clinical Pearl", + "value": "Grapefruit irreversibly blocks intestinal CYP3A4 for up to 72 hours. One glass can double felodipine bioavailability, leading to shock." + } + ] + }, + { + "slug": "nifedipine-xr", + "name": "Nifedipine XR", + "class": "Antihypertensive", + "subclass": "Calcium Channel Blocker", + "category": "Cardiovascular - Antihypertensives", + "accent": "#0284c7", + "tag": "CCB", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "120 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "15 h (XR)", + "cls": "", + "flag": "" + }, + { + "label": "Edema", + "value": "COMMON", + "cls": "warn", + "flag": "" + }, + { + "label": "IR Form", + "value": "AVOID", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent dihydropyridine CCB. The extended-release (XR/OROS) formulation is safe and effective for BP control, but immediate-release forms are dangerous in hypertension.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **120 mg/day** (XR formulations only).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never use short-acting sublingual or chewed nifedipine for hypertensive urgencies due to risk of fatal cerebral/myocardial ischemia.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Nifedipine XR is a potent antihypertensive safe in pregnancy (gestational hypertension), but short-acting/sublingual nifedipine must never be used due to risk of stroke and MI.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Peripheral oedema. MODERATE — Reflex tachycardia, flushing, hypotension.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Constipation, gingival hyperplasia (more common than amlodipine).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertension (XR)", + "val": "**PO** 30-60 mg **OD**. May titrate up to Max **120 mg/day**.", + "tags": [] + }, + { + "key": "Chronic Stable Angina", + "val": "**PO** 30-60 mg **OD**.", + "tags": [] + }, + { + "key": "Pregnancy HTN (Specialist)", + "val": "**PO** 20-30 mg (XR) **OD** or **BD** depending on the specific product release kinetics.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Adalat OROS, Adefin XL, Nifehexal", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Extended-release tablets (30 mg, 60 mg). OROS tablets leave a 'ghost' shell in stool.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension, angina.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Tocolysis in premature labour, Raynaud's phenomenon, High-altitude pulmonary oedema.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Widely used in pregnancy-induced hypertension where ACEi/ARBs are strictly contraindicated.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Acute STEMI (within 8 days), cardiogenic shock, severe aortic stenosis.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "CAUTION — OROS tablets should be avoided in patients with severe strictures or bowel obstruction due to the non-deformable tablet shell.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C; modified-release nifedipine is widely used in specialist maternal medicine when benefits outweigh risks.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Nifedipine XR pregnancy row is a specialist benefit-risk caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP3A4** inhibitors significantly increase levels (avoid grapefruit juice).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CAUTION — Magnesium sulfate (used in pre-eclampsia) plus nifedipine can cause profound neuromuscular blockade and hypotension.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Regular **BP** and **HR** monitoring. Check for lower limb oedema.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Ghost Pill", + "val": "Warn patients taking Adalat OROS that the empty tablet shell will pass through the GI tract and appear intact in their stool—this is normal and the drug has been absorbed.", + "tags": [] + }, + { + "key": "The IR Danger", + "val": "Biting or piercing IR capsules for 'rapid' BP drops causes uncontrolled vasodilation, stealing blood from the heart/brain. It is obsolete and dangerous.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits calcium ion influx into vascular smooth muscle, promoting potent vasodilation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 6 hours (OROS pump system).", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "15 hours (effective half-life driven by the osmotic pump mechanism).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ADALAT OROS/nifedipine Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Calcium Channel Blocker — Potent dihydropyridine CCB." + }, + { + "label": "Route / Formulation", + "value": "Extended-release tablets (30 mg, 60 mg). OROS tablets leave a 'ghost' shell in stool. (Adalat OROS, Adefin XL, Nifehexal)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 30-60 mg **OD**. May titrate up to Max **120 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Hypertension (XR): **PO** 30-60 mg **OD**. May titrate up to Max **120 mg/day**. Chronic Stable Angina: **PO** 30-60 mg **OD**. Pregnancy HTN (Specialist): **PO** 20-30 mg (XR) **OD** or **BD** depending on the specific product release kinetics." + }, + { + "label": "Best Uses", + "value": "Nifedipine XR is a potent antihypertensive safe in pregnancy (gestational hypertension), but short-acting/sublingual nifedipine must never be used due to risk of stroke and MI." + }, + { + "label": "Avoid / Cautions", + "value": "Acute STEMI (within 8 days), cardiogenic shock, severe aortic stenosis. **Pregnancy** Category C, but XR widely used as standard of care in maternal medicine." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Peripheral oedema. MODERATE — Reflex tachycardia, flushing, hypotension. Gastrointestinal: Constipation, gingival hyperplasia (more common than amlodipine)." + }, + { + "label": "Key Interactions", + "value": "**CYP3A4** inhibitors significantly increase levels (avoid grapefruit juice). Magnesium sulfate (used in pre-eclampsia) plus nifedipine can cause profound neuromuscular blockade and hypotension." + }, + { + "label": "Monitoring", + "value": "Regular **BP** and **HR** monitoring. Check for lower limb oedema. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Warn patients taking Adalat OROS that the empty tablet shell will pass through the GI tract and appear intact in their stool—this is normal and the drug has been absorbed." + } + ] + }, + { + "slug": "perindopril", + "name": "Perindopril", + "class": "Antihypertensive", + "subclass": "ACE Inhibitor", + "category": "Cardiovascular - Antihypertensives", + "accent": "#0284c7", + "tag": "ACEi", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "17 h (Active)", + "cls": "", + "flag": "" + }, + { + "label": "Dry Cough", + "value": "COMMON", + "cls": "warn", + "flag": "" + }, + { + "label": "Teratogenic", + "value": "CRITICAL RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Long-acting Angiotensin-Converting Enzyme (ACE) inhibitor. The absolute gold-standard foundational therapy for hypertension, heart failure, and diabetic nephropathy.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day**. Reduce in Renal impairment — Max 2.5 mg/day if **eGFR** < 30.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Absolutely contraindicated in Pregnancy (Category D). Causes severe fetal renal agenesis and skull hypoplasia. Cease immediately on confirmed pregnancy.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Perindopril is the preferred ACE inhibitor for most cardiovascular and renal-protective indications, but must never be used in Pregnancy and always requires **U&E** monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal", + "val": "HIGH — Hyperkalemia, Acute Kidney Injury (AKI) if initiated in bilateral renal artery stenosis or hypovolemia.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Persistent, dry, tickly cough (Occurs in ~10-15% of patients due to bradykinin accumulation).", + "tags": [] + }, + { + "key": "Immunological", + "val": "CRITICAL — Angioedema (swelling of lips/tongue/airway). Can occur years after starting.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertension / Heart Failure", + "val": "Start **PO** 2.5 mg **OD**. Titrate up every 2-4 weeks to target 5-10 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Halve the dose if **eGFR** 30-60. Max 2.5 mg/day if **eGFR** < 30. Monitor K+ strictly.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Coversyl, Perindo", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (2.5, 5, 10 mg). Often combined with Amlodipine (Reaptan) or Indapamide (Coversyl Plus).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension, Heart Failure (HFrEF), prevention of progressive diabetic nephropathy, post-MI remodeling prevention.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line agent for almost all cardiovascular and renal-protective indications.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of ACEi-induced angioedema. Bilateral renal artery stenosis.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Must be ceased immediately upon conception.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Triple Whammy", + "val": "CRITICAL — ACEi + Diuretic + NSAID (Ibuprofen/Naproxen). This combination guarantees acute renal failure by destroying both afferent and efferent glomerular blood flow.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Potassium-sparing diuretics (Spironolactone), K+ supplements (Severe hyperkalemia).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **U&E** (Creatinine, Potassium) 1-2 weeks after starting or changing the dose. A mild creatinine bump (<30%) is normal and protective; a large bump indicates AKI.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Check lying and standing **BP**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Cough Switch", + "val": "If a patient develops the ACEi dry cough, DO NOT prescribe cough medicine. It will not work. Stop the Perindopril and switch them to an ARB (like Candesartan or Irbesartan), which does not affect bradykinin.", + "tags": [] + }, + { + "key": "The First-Dose Drop", + "val": "Patients taking high-dose diuretics are deeply reliant on the RAAS system to maintain blood pressure. Giving them their first dose of an ACEi can cause a sudden, massive syncopal crash (First-Dose Hypotension).", + "tags": [] + }, + { + "key": "The 30% Rule", + "val": "It is normal for creatinine to rise 15-30% after starting an ACEi — this is the intended effect of reducing glomerular hyperfiltration. Junior staff often panic and stop the drug unnecessarily. Only stop if creatinine rises > 30% from baseline, or potassium climbs above 5.5 mmol/L.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitively inhibits ACE, preventing the conversion of Angiotensin I to Angiotensin II (a potent vasoconstrictor). Also prevents the breakdown of bradykinin (leading to the classic dry cough).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Prodrug. Active metabolite (perindoprilat) has a half-life of ~17 hours. Renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Best Uses & Selection", + "type": "sel", + "rows": [ + { + "key": "Ideal Patient", + "val": "Patient with hypertension plus any of: diabetic nephropathy, Heart Failure (HFrEF), post-MI remodelling, or proteinuria. Particularly valuable when a single agent needs to address both BP and renal protection simultaneously.", + "tags": [] + }, + { + "key": "Over ARBs (Candesartan)", + "val": "Choose Perindopril over ARBs when: cost is a significant concern (cheaper on PBS), or the patient has not previously experienced ACEi-related cough. ARBs are preferred when: cough develops, angioedema history, or patient preference.", + "tags": [] + }, + { + "key": "Over Other ACEis", + "val": "Longer half-life than Captopril (once-daily dosing improves adherence). Equivalent efficacy to Ramipril. Strong evidence specifically in stable coronary artery disease (EUROPA trial).", + "tags": [] + }, + { + "key": "Avoid When", + "val": "Avoid in: any patient planning or currently pregnant, bilateral renal artery stenosis, prior ACEi angioedema, hyperkalaemia > 5.5 mmol/L, severe aortic stenosis, or volume-depleted patients without ability to monitor **U&E** within 1-2 weeks.", + "tags": [] + } + ] + }, + { + "title": "Pros & Cons", + "type": "comp", + "rows": [ + { + "key": "Advantages", + "val": "Once-daily dosing (excellent adherence). Dual benefit: antihypertensive + renal-protective in diabetic nephropathy. Strong post-MI evidence (EUROPA trial). Cheap on PBS. Can be combined with almost all antihypertensive classes.", + "tags": [] + }, + { + "key": "Disadvantages", + "val": "Class-specific dry cough in 10-15% (often leads to switching). Requires baseline and ongoing **U&E** monitoring. Absolute contraindication in Pregnancy limits use in women of reproductive age. Risk of first-dose hypotension in volume-depleted patients.", + "tags": [] + }, + { + "key": "Monitoring Burden", + "val": "**U&E** at baseline, 1-2 weeks after starting and each dose change, then 6-12 monthly. Moderate burden vs calcium channel blockers (no monitoring needed), similar to ARBs.", + "tags": [] + }, + { + "key": "Adherence Fit", + "val": "Once daily, no food restrictions, widely available. Good adherence profile. Cough is the primary driver of non-adherence and switching.", + "tags": [] + }, + { + "key": "Overdose Profile", + "val": "Severe hypotension is the primary concern in overdose. Supportive care with **IV** fluids and vasopressors if needed. Not lethal in isolation but dangerous in combination with other antihypertensives. Not removed by dialysis.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: COVERSYL/perindopril Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "ACE Inhibitor — first-line antihypertensive, heart failure, renal protection" + }, + { + "label": "Route / Formulation", + "value": "**PO** tablets: 2.5 mg, 5 mg, 10 mg (Coversyl, Perindo)" + }, + { + "label": "Usual Dose & Max", + "value": "Start 2.5 mg **OD**, titrate to 5-10 mg **OD**. Max 10 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "HF: start 2.5 mg **OD**, target 10 mg **OD**. Renal: halve if **eGFR** 30-60." + }, + { + "label": "Administration", + "value": "Take same time daily. Swallow whole. No food restriction. Missed dose: skip if < 4 h to next." + }, + { + "label": "Best Uses", + "value": "Hypertension + diabetic nephropathy, HFrEF, post-MI. Cheap on PBS. Once-daily." + }, + { + "label": "Avoid / Cautions", + "value": "Pregnancy (Category D), bilateral renal artery stenosis, prior ACEi angioedema, K+ > 5.5 mmol/L." + }, + { + "label": "Key Risks", + "value": "Dry cough 10-15%, first-dose hypotension, angioedema (rare but fatal), hyperkalaemia." + }, + { + "label": "Key Interactions", + "value": "Triple Whammy (ACEi + diuretic + NSAID = AKI). K+-sparing diuretics. Aliskiren in diabetes." + }, + { + "label": "Monitoring", + "value": "**U&E** at baseline, 1-2 weeks post-start, each dose change, then 6-12 monthly. **BP** at each visit." + }, + { + "label": "Clinical Pearl", + "value": "Creatinine rise up to 30% is expected and protective — only stop if > 30% or K+ > 5.5 mmol/L." + } + ] + }, + { + "slug": "verapamil", + "name": "Verapamil", + "class": "Antihypertensive", + "subclass": "Non-DHP CCB", + "category": "Cardiovascular - Antihypertensives", + "accent": "#0284c7", + "tag": "NON-DHP CCB", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "480 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3–7 h", + "cls": "", + "flag": "" + }, + { + "label": "Constipation", + "value": "HIGH", + "cls": "warn", + "flag": "" + }, + { + "label": "Heart Block", + "value": "AVOID", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Non-dihydropyridine CCB. Exerts potent negative inotropic and negative chronotropic effects. Acts heavily on the AV node.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **480 mg/day** (usually divided or as SR).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "NEVER co-administer with beta-blockers due to the risk of fatal complete heart block and asystole.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Verapamil is the preferred CCB for rate control in AF/SVT, but must never be combined with beta-blockers due to risk of fatal bradycardia and AV block.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Bradycardia, AV block, worsening of HFrEF, hypotension.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe constipation (especially in the elderly).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "MODERATE — Dizziness, headache.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertension / Angina", + "val": "**PO** 160-240 mg/day in divided doses, or 180-240 mg SR **OD**. Max **480 mg/day**.", + "tags": [] + }, + { + "key": "SVT / AF Rate Control", + "val": "**PO** 40-120 mg **TDS**.", + "tags": [] + }, + { + "key": "Acute SVT (IV)", + "val": "**IV** 5-10 mg over 2-3 mins under continuous **ECG** and **BP** monitoring. (Specialist only).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Isoptin, Isoptin SR, Veracaps SR", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (40 mg, 80 mg). SR Tablets (180 mg, 240 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (5 mg/2 mL) for **IV** use.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension, angina, SVT termination, AF rate control.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Cluster headache prophylaxis.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Alternative to beta-blockers for rate control in AF, especially in asthmatic patients.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Heart failure with reduced ejection fraction (HFrEF), 2nd/3rd degree AV block, WPW syndrome with AF, sick sinus syndrome.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "HIGH — Extensive first-pass metabolism. Reduce dose by 70% in severe **Hepatic** impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "hepatic": ["severe"] + }, + "note": "Verapamil hepatic impairment row should prompt dose reduction/review rather than automatic contraindication." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Verapamil pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Beta-blockers (oral or IV). The combination leads to profound bradycardia, complete heart block, and cardiogenic shock.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Moderate **CYP3A4** inhibitor. Massively increases levels of Simvastatin/Atorvastatin (myopathy risk) and Digoxin.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline and ongoing **ECG** to ensure PR interval is normal. Monitor **HR** and **BP**.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — **LFTs** (hepatic clearance) and monitor interacting drug levels (e.g., **TDM** for Digoxin).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Bowel Block", + "val": "Constipation is extremely common and dose-limiting in older adults. Proactively prescribe a laxative if starting high doses.", + "tags": [] + }, + { + "key": "The Asthma Swap", + "val": "If an asthmatic patient has rapid AF and cannot tolerate metoprolol, Verapamil or Diltiazem are the rate-control drugs of choice.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits calcium channels centrally (myocardium/AV node) and peripherally. Slows SA/AV nodal conduction and reduces contractility.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours. **IV** 1-5 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-7 hours (IR) / Prolonged with SR and in hepatic dysfunction.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ISOPTIN/verapamil Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Non-DHP CCB — Non-dihydropyridine CCB." + }, + { + "label": "Route / Formulation", + "value": "Tablets (40 mg, 80 mg). SR Tablets (180 mg, 240 mg). (Isoptin, Isoptin SR, Veracaps SR)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 160-240 mg/day in divided doses, or 180-240 mg SR **OD**. Max **480 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Hypertension / Angina: **PO** 160-240 mg/day in divided doses, or 180-240 mg SR **OD**. Max **480 mg/day**. SVT / AF Rate Control: **PO** 40-120 mg **TDS**. Acute SVT (IV): **IV** 5-10 mg over 2-3 mins under continuous **ECG** and **BP** monitoring. (Specialist only)." + }, + { + "label": "Best Uses", + "value": "Verapamil is the preferred CCB for rate control in AF/SVT, but must never be combined with beta-blockers due to risk of fatal bradycardia and AV block." + }, + { + "label": "Avoid / Cautions", + "value": "Heart failure with reduced ejection fraction (HFrEF), 2nd/3rd degree AV block, WPW syndrome with AF, sick sinus syndrome. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Bradycardia, AV block, worsening of HFrEF, hypotension. Gastrointestinal: Severe constipation (especially in the elderly). Neurological: Dizziness, headache." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers (oral or IV). The combination leads to profound bradycardia, complete heart block, and cardiogenic shock. Moderate **CYP3A4** inhibitor. Massively increases levels of Simvastatin/Atorvastatin (myopathy risk) and Digoxin." + }, + { + "label": "Monitoring", + "value": "Baseline and ongoing **ECG** to ensure PR interval is normal. Monitor **HR** and **BP**. **LFTs** (hepatic clearance) and monitor interacting drug levels (e.g., **TDM** for Digoxin)." + }, + { + "label": "Clinical Pearl", + "value": "Constipation is extremely common and dose-limiting in older adults. Proactively prescribe a laxative if starting high doses." + } + ] + }, + { + "slug": "atenolol", + "name": "Atenolol", + "class": "Antihypertensive", + "subclass": "Beta Blocker", + "category": "Cardiovascular - Beta Blockers", + "accent": "#0284c7", + "tag": "BETA BLOCKER", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "100 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6–7 h", + "cls": "", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Asthma", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Water-soluble, cardioselective beta-blocker. Unlike metoprolol, it relies heavily on renal clearance and does not cross the blood-brain barrier easily.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **100 mg/day**", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be dose-reduced in renal impairment to prevent profound drug accumulation and severe bradycardia.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Atenolol is a simple once-daily beta-blocker for rate control and angina, but has fallen out of favour as first-line for hypertension due to inferior stroke outcomes.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Bradycardia, AV block, heart failure exacerbation.", + "tags": [] + }, + { + "key": "Renal", + "val": "HIGH — Toxicity/accumulation rapidly occurs with declining renal function.", + "tags": [] + }, + { + "key": "Neurological", + "val": "LOW — Being hydrophilic, it causes fewer CNS side effects (nightmares, sleep issues) than lipophilic agents like metoprolol.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertension / Angina", + "val": "**PO** 25-50 mg **OD**. Max **100 mg/day**.", + "tags": [] + }, + { + "key": "AF Rate Control", + "val": "**PO** 25-50 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "If **eGFR** 15-35, Max 50 mg/day. If **eGFR** < 15, Max 25 mg/day or give every 48 hours.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Tenormin, Noten", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (50 mg, 100 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (5 mg/10 mL) for **IV** use (Rarely used, specialist only).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension, angina, arrhythmias.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Historically widely used, but inferior to ACEi/ARBs for primary hypertension. Still useful for rate control.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe asthma, 2nd/3rd degree heart block, cardiogenic shock.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Dose MUST be adjusted based on **eGFR**.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 35 + } + }, + "note": "Atenolol renal impairment row should prompt dose reduction/review rather than automatic contraindication." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C. Associated with intrauterine growth restriction (IUGR).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Atenolol pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Verapamil and Diltiazem (Risk of asystole).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Digoxin, Amiodarone.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and routine **U&E** and **eGFR** to guide safe dosing.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Hold if **HR** < 50 or SBP < 90.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Renal Trap", + "val": "The most common cause of Atenolol-induced severe bradycardia in the elderly is an acute decline in renal function. Always check the **eGFR** before increasing the dose.", + "tags": [] + }, + { + "key": "No Heart Failure Evidence", + "val": "Unlike Bisoprolol, Metoprolol Succinate, and Carvedilol, Atenolol has NO mortality benefit data in HFrEF. Do not use it for this indication.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selective Beta-1 adrenoceptor antagonist. Decreases HR, contractility, and renin release.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2-4 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "6-7 hours (Massively prolonged in renal failure due to hydrophilic nature).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: TENORMIN/atenolol Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Beta Blocker — Water-soluble, cardioselective beta-blocker." + }, + { + "label": "Route / Formulation", + "value": "Tablets (50 mg, 100 mg). (Tenormin, Noten)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 25-50 mg **OD**. Max **100 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Hypertension / Angina: **PO** 25-50 mg **OD**. Max **100 mg/day**. AF Rate Control: **PO** 25-50 mg **OD**. Renal Impairment: If **eGFR** 15-35, Max 50 mg/day. If **eGFR** < 15, Max 25 mg/day or give every 48 hours." + }, + { + "label": "Best Uses", + "value": "Atenolol is a simple once-daily beta-blocker for rate control and angina, but has fallen out of favour as first-line for hypertension due to inferior stroke outcomes." + }, + { + "label": "Avoid / Cautions", + "value": "Severe asthma, 2nd/3rd degree heart block, cardiogenic shock. **Pregnancy** Category C. Associated with intrauterine growth restriction (IUGR)." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Bradycardia, AV block, heart failure exacerbation. Renal: Toxicity/accumulation rapidly occurs with declining renal function. Neurological: Being hydrophilic, it causes fewer CNS side effects (nightmares, sleep issues) than lipophilic agents like metoprolol." + }, + { + "label": "Key Interactions", + "value": "Verapamil and Diltiazem (Risk of asystole). Digoxin, Amiodarone." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **U&E** and **eGFR** to guide safe dosing. Hold if **HR** < 50 or SBP < 90." + }, + { + "label": "Clinical Pearl", + "value": "The most common cause of Atenolol-induced severe bradycardia in the elderly is an acute decline in renal function. Always check the **eGFR** before increasing the dose." + } + ] + }, + { + "slug": "bisoprolol", + "name": "Bisoprolol", + "class": "Antihypertensive", + "subclass": "Beta Blocker", + "category": "Cardiovascular - Beta Blockers", + "accent": "#0284c7", + "tag": "BETA BLOCKER", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10–12 h", + "cls": "", + "flag": "" + }, + { + "label": "Cardioselective", + "value": "YES", + "cls": "good", + "flag": "" + }, + { + "label": "Heart Failure", + "value": "INDICATED", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly cardioselective (Beta-1) beta-blocker. Exceptional evidence base for reducing mortality in chronic heart failure with reduced ejection fraction (HFrEF).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day**", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Titration in heart failure must be 'start low, go slow' to prevent acute decompensation.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Bisoprolol is the most cardioselective beta-blocker with strong heart failure mortality evidence, but must be up-titrated slowly and never stopped abruptly.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Bradycardia, heart block. MODERATE — Initial worsening of heart failure symptoms during early titration.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "MODERATE — Bronchospasm (though highly selective, risk still exists in severe asthma).", + "tags": [] + }, + { + "key": "Other", + "val": "LOW — Fatigue, cold extremities, masked hypoglycaemia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Heart Failure (HFrEF)", + "val": "**PO** 1.25 mg **OD**. Double dose every 2-4 wks based on tolerance. Target Max **10 mg/day**.", + "tags": [] + }, + { + "key": "Hypertension / Angina", + "val": "**PO** 2.5-5 mg **OD**. Max **10 mg/day**.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Strictly start at 1.25 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Bicor, Bisoprolol Sandoz", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (1.25 mg, 2.5 mg, 5 mg, 10 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Stable chronic HFrEF, hypertension, angina.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "One of the three core beta-blockers (alongside carvedilol and metoprolol succinate) with proven mortality benefit in HFrEF.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Acute decompensated heart failure, cardiogenic shock, 2nd/3rd degree heart block, severe asthma.", + "tags": [] + }, + { + "key": "Renal & Hepatic", + "val": "CAUTION — Max dose 10 mg/day is safe, but titrate slower if severe **Renal** (**eGFR** < 20) or **Hepatic** impairment exist.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 20 + }, + "hepatic": ["severe"] + }, + "note": "Bisoprolol severe renal/hepatic impairment should prompt cautious titration and review rather than automatic contraindication." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Bisoprolol pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Non-DHP CCBs (Verapamil, Diltiazem) due to profound AV node blockade.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Amiodarone and Digoxin (additive bradycardia).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Hold if **HR** < 50 or SBP < 90. In heart failure, daily **Weight** is required to catch early decompensation during titration.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Baseline **ECG** required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Decompensation Dip", + "val": "When starting Bisoprolol in HFrEF, the negative inotropic effect often makes patients feel worse (fatigued, slightly more breathless) for 1-2 weeks before they improve. Warn them to expect this.", + "tags": [] + }, + { + "key": "Asthma Safety", + "val": "Bisoprolol is one of the most Beta-1 selective agents available. If a beta-blocker is absolutely necessary in a mild/moderate asthmatic, it is a safer choice than Carvedilol.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Highly selective Beta-1 adrenoceptor antagonist. Slows HR and decreases myocardial workload.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h (Allows for true **OD** dosing).", + "tags": [] + }, + { + "key": "Half-life", + "val": "10-12 hours. Cleared 50% renally, 50% hepatically.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: BICOR/bisoprolol Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Beta Blocker — Highly cardioselective (Beta-1) beta-blocker." + }, + { + "label": "Route / Formulation", + "value": "Tablets (1.25 mg, 2.5 mg, 5 mg, 10 mg). (Bicor, Bisoprolol Sandoz)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1.25 mg **OD**. Double dose every 2-4 wks based on tolerance. Target Max **10 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Heart Failure (HFrEF): **PO** 1.25 mg **OD**. Double dose every 2-4 wks based on tolerance. Target Max **10 mg/day**. Hypertension / Angina: **PO** 2.5-5 mg **OD**. Max **10 mg/day**. Elderly / Frail: Strictly start at 1.25 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Bisoprolol is the most cardioselective beta-blocker with strong heart failure mortality evidence, but must be up-titrated slowly and never stopped abruptly." + }, + { + "label": "Avoid / Cautions", + "value": "Acute decompensated heart failure, cardiogenic shock, 2nd/3rd degree heart block, severe asthma. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Bradycardia, heart block. MODERATE — Initial worsening of heart failure symptoms during early titration. Respiratory: Bronchospasm (though highly selective, risk still exists in severe asthma). Other: Fatigue, cold extremities, masked hypoglycaemia." + }, + { + "label": "Key Interactions", + "value": "Non-DHP CCBs (Verapamil, Diltiazem) due to profound AV node blockade. Amiodarone and Digoxin (additive bradycardia)." + }, + { + "label": "Monitoring", + "value": "Hold if **HR** < 50 or SBP < 90. In heart failure, daily **Weight** is required to catch early decompensation during titration. Baseline **ECG** required." + }, + { + "label": "Clinical Pearl", + "value": "When starting Bisoprolol in HFrEF, the negative inotropic effect often makes patients feel worse (fatigued, slightly more breathless) for 1-2 weeks before they improve. Warn them to expect this." + } + ] + }, + { + "slug": "carvedilol", + "name": "Carvedilol", + "class": "Antihypertensive", + "subclass": "Alpha/Beta Blocker", + "category": "Cardiovascular - Beta Blockers", + "accent": "#0284c7", + "tag": "BETA BLOCKER", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "50 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "7–10 h", + "cls": "", + "flag": "" + }, + { + "label": "Freq", + "value": "BD Dosing", + "cls": "warn", + "flag": "" + }, + { + "label": "Heart Failure", + "value": "1ST LINE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Non-selective beta-blocker with additional alpha-1 blocking (vasodilating) activity. A powerhouse medication with robust mortality benefits in heart failure.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **50 mg/day** (given as 25 mg **BD**). Max 100 mg/day if > 85 kg.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Because of its alpha-1 blockade, it causes more initial hypotension than other beta-blockers. Up-titrate strictly every 2 weeks.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Carvedilol is a dual alpha/beta blocker with mortality benefit in heart failure, but causes more dizziness and orthostatic hypotension than selective beta-blockers.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Postural hypotension (due to alpha blockade), bradycardia, fluid retention during initiation.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Bronchospasm (non-selective beta-blockade means high risk in asthmatics).", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Dizziness, fatigue, masking of hypoglycemia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Heart Failure (HFrEF)", + "val": "Start **PO** 3.125 mg **BD**. Double dose every 2 weeks. Target 25 mg **BD**.", + "tags": [] + }, + { + "key": "Hypertension / Angina", + "val": "**PO** 12.5 mg **BD**. Max 25 mg **BD**.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Strictly start at 3.125 mg **BD** and take with food to slow absorption and reduce hypotension.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dilatrend, Dicarz", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (3.125 mg, 6.25 mg, 12.5 mg, 25 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "HFrEF, hypertension, post-MI.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Core pillar of HFrEF management alongside ACEi/ARNI, MRA, and SGLT2i.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe asthma/COPD, severe hepatic impairment, acute decompensated heart failure, 2nd/3rd degree heart block.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Carvedilol is contraindicated in severe hepatic impairment." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Carvedilol pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + }, + { + "key": "Hepatic Impairment", + "val": "CAUTION — Reduced clearance; use lower doses and monitor closely.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "hepatic": ["mild", "moderate"] + }, + "note": "Carvedilol hepatic impairment row should prompt dose review/monitoring; severe hepatic impairment is handled by the absolute contraindication row." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Verapamil/Diltiazem (asystole risk). Additive hypotension with other alpha-blockers (e.g., Prazosin).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "MODERATE — Increases Digoxin levels by ~15%.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **BP** (specifically postural drop) and **Weight** (fluid retention) during up-titration.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Baseline **ECG**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Food Slows the Drop", + "val": "Taking Carvedilol with food slows its absorption, blunting the peak concentration and significantly reducing the risk of orthostatic hypotension.", + "tags": [] + }, + { + "key": "The Asthma Rule", + "val": "Because it blocks Beta-2 receptors as well as Beta-1, it is much more likely to trigger asthma attacks than Bisoprolol or Metoprolol. Avoid in true asthmatics.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Non-selective Beta-1 and Beta-2 blockade. Alpha-1 blockade reduces peripheral resistance (vasodilation). Has antioxidant properties.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12 h (Strictly requires **BD** dosing).", + "tags": [] + }, + { + "key": "Half-life", + "val": "7-10 hours. Extensive hepatic metabolism (CYP2D6, CYP2C9).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: DILATREND/carvedilol Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha/Beta Blocker — Non-selective beta-blocker with additional alpha-1 blocking (vasodilating) activity." + }, + { + "label": "Route / Formulation", + "value": "Tablets (3.125 mg, 6.25 mg, 12.5 mg, 25 mg). (Dilatrend, Dicarz)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 3.125 mg **BD**. Double dose every 2 weeks. Target 25 mg **BD**. Max **50 mg/day** (given as 25 mg **BD**)." + }, + { + "label": "Key Indication Doses", + "value": "Heart Failure (HFrEF): Start **PO** 3.125 mg **BD**. Double dose every 2 weeks. Target 25 mg **BD**. Hypertension / Angina: **PO** 12.5 mg **BD**. Max 25 mg **BD**. Elderly / Frail: Strictly start at 3.125 mg **BD** and take with food to slow absorption and reduce hypotension." + }, + { + "label": "Best Uses", + "value": "Carvedilol is a dual alpha/beta blocker with mortality benefit in heart failure, but causes more dizziness and orthostatic hypotension than selective beta-blockers." + }, + { + "label": "Avoid / Cautions", + "value": "Severe asthma/COPD, severe hepatic impairment, acute decompensated heart failure, 2nd/3rd degree heart block. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Postural hypotension (due to alpha blockade), bradycardia, fluid retention during initiation. Respiratory: Bronchospasm (non-selective beta-blockade means high risk in asthmatics). Neurological: Dizziness, fatigue, masking of hypoglycemia." + }, + { + "label": "Key Interactions", + "value": "Verapamil/Diltiazem (asystole risk). Additive hypotension with other alpha-blockers (e.g., Prazosin). Increases Digoxin levels by ~15%." + }, + { + "label": "Monitoring", + "value": "Monitor **BP** (specifically postural drop) and **Weight** (fluid retention) during up-titration. Baseline **ECG**." + }, + { + "label": "Clinical Pearl", + "value": "Taking Carvedilol with food slows its absorption, blunting the peak concentration and significantly reducing the risk of orthostatic hypotension." + } + ] + }, + { + "slug": "labetalol", + "name": "Labetalol", + "class": "Antihypertensive", + "subclass": "Alpha/Beta Blocker", + "category": "Cardiovascular - Beta Blockers", + "accent": "#0284c7", + "tag": "BETA BLOCKER", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "2400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5–8 h", + "cls": "", + "flag": "" + }, + { + "label": "Pregnancy", + "value": "SAFE", + "cls": "good", + "flag": "" + }, + { + "label": "Hepatic", + "value": "MONITOR", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Combined non-selective beta and alpha-1 blocker. Its primary modern utility is the management of hypertension in pregnancy and hypertensive emergencies.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2400 mg/day** (in severe refractory cases, usually in divided doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Safe in pregnancy. **IV** formulation acts rapidly for hypertensive emergencies but requires strict continuous monitoring.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Labetalol is the first-line IV and oral antihypertensive in pregnancy and hypertensive emergencies, but causes significant orthostatic hypotension and must never be used in asthma.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Orthostatic hypotension, bradycardia.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "MODERATE — Rare but severe hepatocellular injury (reversible on cessation).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Respiratory", + "val": "MODERATE — Bronchospasm in susceptible individuals.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Pregnancy HTN (Oral)", + "val": "**PO** 100-200 mg **BD**. Titrate up rapidly if needed. Max 2400 mg/day (usually divided TDS/QID at high doses).", + "tags": [] + }, + { + "key": "Hypertensive Emergency", + "val": "**IV** 20 mg over about 2 mins; may give 40 mg then up to three further 80 mg boluses every 10-20 mins if required. Infusion in severe hypertension in pregnancy: start 20 mg/hr and increase by 20 mg/hr every 20 mins to max 160 mg/hr.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Start at **PO** 50 mg **BD** due to significant orthostatic hypotension risk.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Trandate", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (100 mg, 200 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (50 mg/10 mL) for **IV** injection/infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension in pregnancy (pre-eclampsia), hypertensive emergencies.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line oral/IV agent in obstetrics. Replaces other beta-blockers when alpha-vasodilation is also desired.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Asthma/COPD, 2nd/3rd degree heart block, severe bradycardia.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C; used for severe hypertension in pregnancy when clinically indicated with maternal and fetal/neonatal monitoring.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Labetalol pregnancy row is a source-backed caution/use-with-monitoring row, not an automatic contraindication alert." + } + }, + { + "key": "Hepatic Impairment", + "val": "CAUTION — Monitor closely in hepatic impairment; stop and do not restart if jaundice or laboratory evidence of labetalol liver injury occurs.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "monitor", + "severity": "caution", + "match": { + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "Labetalol hepatic row should prompt monitoring and avoidance of rechallenge after labetalol-induced liver injury rather than automatic contraindication for all hepatic impairment." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive hypotension with halothane/anaesthetics. Bradycardia with non-DHP CCBs.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Continuous **BP** and **ECG** monitoring during **IV** administration. Monitor for postural drops with oral dosing.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and routine **LFTs** (stop drug if jaundice or significant transaminitis occurs).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Tingling Scalp", + "val": "Labetalol frequently causes a harmless but intensely annoying tingling or formication of the scalp (the 'labetalol tingle'). Reassure the patient.", + "tags": [] + }, + { + "key": "Urine False Positives", + "val": "Can cause false-positive urinary catecholamine tests, complicating pheochromocytoma screening.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Ratio of beta to alpha blockade is 3:1 (oral) and 7:1 (IV). Lowers BP via decreased peripheral resistance without significant reflex tachycardia.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours. **IV** 5 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5-8 hours. Extensive first-pass hepatic metabolism.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: LABETALOL SXP Australian PI and Trandate ARTG source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha/Beta Blocker — Combined non-selective beta and alpha-1 blocker." + }, + { + "label": "Route / Formulation", + "value": "Tablets (100 mg, 200 mg). (Trandate)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 100-200 mg **BD**. Titrate up rapidly if needed. Max 2400 mg/day (usually divided TDS/QID at high doses)." + }, + { + "label": "Key Indication Doses", + "value": "Pregnancy HTN (Oral): **PO** 100-200 mg **BD**. Titrate up rapidly if needed. Max 2400 mg/day (usually divided TDS/QID at high doses). Hypertensive Emergency: **IV** 20 mg over about 2 mins; may give 40 mg then up to three further 80 mg boluses every 10-20 mins if required. Infusion in severe hypertension in pregnancy: start 20 mg/hr and increase by 20 mg/hr every 20 mins to max 160 mg/hr. Elderly / Frail: Start at **PO** 50 mg **BD** due to significant orthostatic hypotension risk." + }, + { + "label": "Best Uses", + "value": "Labetalol is the first-line IV and oral antihypertensive in pregnancy and hypertensive emergencies, but causes significant orthostatic hypotension and must never be used in asthma." + }, + { + "label": "Avoid / Cautions", + "value": "Asthma/COPD, 2nd/3rd degree heart block, severe bradycardia. **Pregnancy** Category C, but extensive historical data confirms safety for maternal HTN." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Orthostatic hypotension, bradycardia. Hepatic: Rare but severe hepatocellular injury (reversible on cessation). Respiratory: Bronchospasm in susceptible individuals." + }, + { + "label": "Key Interactions", + "value": "Additive hypotension with halothane/anaesthetics. Bradycardia with non-DHP CCBs." + }, + { + "label": "Monitoring", + "value": "Continuous **BP** and **ECG** monitoring during **IV** administration. Monitor for postural drops with oral dosing. Baseline and routine **LFTs** (stop drug if jaundice or significant transaminitis occurs)." + }, + { + "label": "Clinical Pearl", + "value": "Labetalol frequently causes a harmless but intensely annoying tingling or formication of the scalp (the 'labetalol tingle'). Reassure the patient." + } + ] + }, + { + "slug": "metoprolol", + "name": "Metoprolol", + "class": "Antihypertensive", + "subclass": "Beta Blocker", + "category": "Cardiovascular - Beta Blockers", + "accent": "#0284c7", + "tag": "BETA BLOCKER", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "200 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3–7 h", + "cls": "", + "flag": "" + }, + { + "label": "Asthma", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "" + }, + { + "label": "Bradycardia", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Cardioselective (Beta-1) adrenergic antagonist. A staple of ward medicine for rate control, angina, and post-MI management.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **200 mg/day** (often divided **BD** for tartrate form).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Tartrate (IR) is used for acute rate control. Succinate (CR) is used for chronic heart failure. Do not mix them up.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Metoprolol is the first-line beta-blocker for heart failure and acute MI with both oral and IV formulations, but requires careful dose titration and must not be stopped abruptly.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Bradycardia, AV block, cardiogenic shock in acute overdose.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Bronchospasm (despite being 'cardioselective', selectivity is lost at high doses).", + "tags": [] + }, + { + "key": "Endocrine", + "val": "MODERATE — Can mask the physiological symptoms of hypoglycemia (tachycardia, tremor) in diabetics.", + "tags": [] + }, + { + "key": "Neurological", + "val": "LOW — Fatigue, vivid dreams, cold extremities.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "AF / Rate Control (Acute)", + "val": "**PO** 25-50 mg (Tartrate) **BD** or **TDS**. May use **IV** 2.5-5 mg slowly (Specialist).", + "tags": [] + }, + { + "key": "Heart Failure (HFrEF)", + "val": "**PO** 11.75 mg or 23.5 mg (Succinate CR) **OD**. Titrate slowly to Max **190 mg OD**.", + "tags": [] + }, + { + "key": "Post-MI / Angina", + "val": "**PO** 50 mg (Tartrate) **BD**. Max **200 mg/day**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Betaloc (Tartrate IR), Betaloc CR, Minax", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tartrate Tablets (50 mg, 100 mg). Succinate CR Tablets (23.5 mg, 47 mg, 95 mg, 190 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (5 mg/5 mL) for **IV** administration (high risk of bradycardia/arrest).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "AF rate control, angina, post-MI, HFrEF (succinate only).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Workhorse beta-blocker on the ward for rapid heart rates. First-line for post-MI cardioprotection.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe asthma, 2nd/3rd degree heart block, sick sinus syndrome, uncompensated acute decompensated heart failure.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C (risk of neonatal bradycardia).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Metoprolol pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + }, + { + "key": "Hepatic Impairment", + "val": "CAUTION — Highly metabolised by the liver. **Hepatic** impairment increases bioavailability.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "Metoprolol hepatic impairment row should prompt dose review/monitoring rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Verapamil and Diltiazem. Concurrent use risks fatal asystole.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (e.g., fluoxetine, paroxetine) will significantly increase metoprolol levels and bradycardia risk.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Hold dose if **HR** < 50 bpm or systolic **BP** < 90 mmHg. Check before every administration.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG** to rule out existing heart block before initiation.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Salt Matters", + "val": "Metoprolol Tartrate is immediate release (dosed BD/TDS). Metoprolol Succinate is controlled release (dosed OD). Succinate is the ONLY form proven to reduce mortality in Heart Failure.", + "tags": [] + }, + { + "key": "The Asthma Myth", + "val": "While 'cardioselective', Metoprolol will still trigger life-threatening bronchospasm in susceptible asthmatics. Use alternative rate-control (like Diltiazem) if asthma is severe.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selective Beta-1 receptor antagonist. Decreases heart rate, contractility, and AV nodal conduction.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours. **IV** 5 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "12 hours (Tartrate), 24 hours (Succinate CR).", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-7 hours (Tartrate undergoes extensive hepatic first-pass metabolism).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: BETALOC/metoprolol Australian PI and TOPROL-XL Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Beta Blocker — Cardioselective (Beta-1) adrenergic antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tartrate Tablets (50 mg, 100 mg). Succinate CR Tablets (23.5 mg, 47 mg, 95 mg, 190 mg). (Betaloc (Tartrate IR), Betaloc CR, Minax)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 25-50 mg (Tartrate) **BD** or **TDS**. May use **IV** 2.5-5 mg slowly (Specialist). Max **200 mg/day** (often divided **BD** for tartrate form)." + }, + { + "label": "Key Indication Doses", + "value": "AF / Rate Control (Acute): **PO** 25-50 mg (Tartrate) **BD** or **TDS**. May use **IV** 2.5-5 mg slowly (Specialist). Heart Failure (HFrEF): **PO** 11.75 mg or 23.5 mg (Succinate CR) **OD**. Titrate slowly to Max **190 mg OD**. Post-MI / Angina: **PO** 50 mg (Tartrate) **BD**. Max **200 mg/day**." + }, + { + "label": "Best Uses", + "value": "Metoprolol is the first-line beta-blocker for heart failure and acute MI with both oral and IV formulations, but requires careful dose titration and must not be stopped abruptly." + }, + { + "label": "Avoid / Cautions", + "value": "Severe asthma, 2nd/3rd degree heart block, sick sinus syndrome, uncompensated acute decompensated heart failure. **Pregnancy** Category C (risk of neonatal bradycardia)." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Bradycardia, AV block, cardiogenic shock in acute overdose. Respiratory: Bronchospasm (despite being 'cardioselective', selectivity is lost at high doses). Endocrine: Can mask the physiological symptoms of hypoglycemia (tachycardia, tremor) in diabetics. Neurological: Fatigue, vivid dreams, cold extremities." + }, + { + "label": "Key Interactions", + "value": "Verapamil and Diltiazem. Concurrent use risks fatal asystole. **CYP2D6** inhibitors (e.g., fluoxetine, paroxetine) will significantly increase metoprolol levels and bradycardia risk." + }, + { + "label": "Monitoring", + "value": "Hold dose if **HR** < 50 bpm or systolic **BP** < 90 mmHg. Check before every administration. Baseline **ECG** to rule out existing heart block before initiation." + }, + { + "label": "Clinical Pearl", + "value": "Metoprolol Tartrate is immediate release (dosed BD/TDS). Metoprolol Succinate is controlled release (dosed OD). Succinate is the ONLY form proven to reduce mortality in Heart Failure." + } + ] + }, + { + "slug": "amiloride", + "name": "Amiloride", + "class": "Diuretic", + "subclass": "Potassium-sparing Diuretic", + "category": "Cardiovascular - Diuretics", + "accent": "#0284c7", + "tag": "K-SPARING", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6–9 h", + "cls": "", + "flag": "" + }, + { + "label": "Hyperkalemia", + "value": "HIGH RISK", + "cls": "hi", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "MANDATORY", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Epithelial sodium channel (ENaC) blocker. A weak diuretic used almost exclusively to counteract the potassium-wasting effects of loop and thiazide diuretics.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day**", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Very high risk of hyperkalemia if given alongside ACEi/ARBs or in renal failure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Amiloride is a potassium-sparing diuretic used to counteract thiazide/loop-induced hypokalaemia, but must be avoided in renal impairment due to dangerous hyperkalaemia risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Electrolytes", + "val": "CRITICAL — Hyperkalemia (can be severe and rapid). Hyponatremia.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Nausea, anorexia.", + "tags": [] + }, + { + "key": "Neurological", + "val": "LOW — Headache, weakness.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Diuretic-induced Hypokalemia", + "val": "**PO** 5-10 mg **OD**. Max **20 mg/day**.", + "tags": [] + }, + { + "key": "Combination Therapy", + "val": "Often formulated directly with HCTZ (e.g., Moduretic).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Kaluril, Moduretic (combo with HCTZ)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention or treatment of hypokalemia caused by other diuretics.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Lithium-induced nephrogenic diabetes insipidus.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Niche utility. Largely superseded by Spironolactone/Eplerenone which offer actual mortality benefits in heart failure.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Baseline hyperkalemia (K+ > 5.0), anuria, severe renal impairment (**eGFR** < 30).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Amiloride is avoided/contraindicated in severe renal impairment because of serious hyperkalaemia risk." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Amiloride pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — ACEi, ARBs, Spironolactone, K+ supplements. Do not use together unless under intense specialist monitoring.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — NSAIDs (exacerbate renal failure and hyperkalemia).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Regular **U&E** monitoring. Cease drug if K+ > 5.0.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Monitor **BP**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Lithium Rescue", + "val": "Amiloride is uniquely useful for patients on Lithium who develop polyuria (diabetes insipidus). It blocks the ENaC channel where Lithium enters the collecting duct cells, halting the toxicity.", + "tags": [] + }, + { + "key": "No Cardiac Remodeling", + "val": "Unlike Spironolactone, Amiloride does NOT block the aldosterone receptor. Therefore, it provides zero anti-fibrotic or mortality benefits in heart failure.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Directly blocks the ENaC channels in the late distal convoluted tubule and collecting duct, independent of aldosterone. Reduces Na+ reabsorption and halts K+ excretion.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "6-9 hours (Excreted entirely unchanged in urine).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: KALURIL/amiloride Australian CMI and MODURETIC Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Potassium-sparing Diuretic — Epithelial sodium channel (ENaC) blocker." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg). (Kaluril, Moduretic (combo with HCTZ))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5-10 mg **OD**. Max **20 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Diuretic-induced Hypokalemia: **PO** 5-10 mg **OD**. Max **20 mg/day**. Combination Therapy: Often formulated directly with HCTZ (e.g., Moduretic)." + }, + { + "label": "Best Uses", + "value": "Amiloride is a potassium-sparing diuretic used to counteract thiazide/loop-induced hypokalaemia, but must be avoided in renal impairment due to dangerous hyperkalaemia risk." + }, + { + "label": "Avoid / Cautions", + "value": "Baseline hyperkalemia (K+ > 5.0), anuria, severe renal impairment (**eGFR** < 30). **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Electrolytes: Hyperkalemia (can be severe and rapid). Hyponatremia. Gastrointestinal: Nausea, anorexia. Neurological: Headache, weakness." + }, + { + "label": "Key Interactions", + "value": "ACEi, ARBs, Spironolactone, K+ supplements. Do not use together unless under intense specialist monitoring. NSAIDs (exacerbate renal failure and hyperkalemia)." + }, + { + "label": "Monitoring", + "value": "Regular **U&E** monitoring. Cease drug if K+ > 5.0. Monitor **BP**." + }, + { + "label": "Clinical Pearl", + "value": "Amiloride is uniquely useful for patients on Lithium who develop polyuria (diabetes insipidus). It blocks the ENaC channel where Lithium enters the collecting duct cells, halting the toxicity." + } + ] + }, + { + "slug": "eplerenone", + "name": "Eplerenone", + "class": "Antihypertensive", + "subclass": "Potassium-sparing Diuretic", + "category": "Cardiovascular - Diuretics", + "accent": "#0284c7", + "tag": "MRA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "50 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4–6 h", + "cls": "", + "flag": "" + }, + { + "label": "Hyperkalemia", + "value": "HIGH RISK", + "cls": "hi", + "flag": "" + }, + { + "label": "Gynecomastia", + "value": "RARE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly selective Mineralocorticoid Receptor Antagonist (MRA). Retains the heart failure mortality benefits of Spironolactone but completely eliminates the hormonal side effects.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **50 mg/day**", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Potassium monitoring is absolutely mandatory, especially when combined with ACEi/ARBs.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Eplerenone is the selective MRA of choice post-MI and in heart failure with proven mortality benefit, but hyperkalaemia risk mandates strict potassium monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Electrolytes", + "val": "CRITICAL — Hyperkalemia (K+ > 5.5 mmol/L).", + "tags": [] + }, + { + "key": "Renal", + "val": "HIGH — Acute renal impairment/AKI.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "monitor", + "severity": "caution", + "note": "Existing row flags acute renal impairment/AKI risk; highlights when renal context is entered." + } + }, + { + "key": "Endocrine", + "val": "LOW — Gynecomastia and menstrual issues are practically zero (highly selective, no affinity for androgen/progesterone receptors).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Heart Failure (Post-MI or Chronic)", + "val": "**PO** 25 mg **OD**. Titrate up after 4 weeks to Max **50 mg OD** (dependent on K+ levels).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "If **eGFR** 30-50, Max 25 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Inspra", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (25 mg, 50 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for heart failure.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "HFrEF, left ventricular dysfunction post-MI.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Direct replacement for Spironolactone in males who develop painful gynecomastia or sexual dysfunction.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Baseline K+ > 5.0 mmol/L, severe renal impairment (**eGFR** < 30).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Eplerenone is contraindicated in severe renal impairment because hyperkalaemia risk increases as renal function declines." + } + }, + { + "key": "Hepatic Impairment", + "val": "CAUTION — Avoid in severe **Hepatic** impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Eplerenone is contraindicated in severe hepatic impairment." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Eplerenone pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Strong **CYP3A4** inhibitors (clarithromycin, itraconazole) massively increase eplerenone levels. Use is contraindicated.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Potassium supplements, ACEi, ARBs (Hyperkalemia).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **U&E** check at day 3, 1 week, 1 month, then 3-monthly. Adjust dose if K+ hits 5.0, withhold if K+ > 5.5.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor **BP** and assess for heart failure symptoms.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Not for BP", + "val": "Unlike Spironolactone, Eplerenone is a very weak blood pressure lowering agent. It is used almost exclusively for its anti-fibrotic, mortality-reducing properties in the heart.", + "tags": [] + }, + { + "key": "The Potassium Trap", + "val": "Educate patients strictly against using 'salt substitutes' (which are essentially pure potassium chloride) while taking this medication, as it can cause sudden fatal arrhythmias.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selectively binds the mineralocorticoid (aldosterone) receptor in the kidney, heart, and blood vessels. Prevents fibrosis and sodium retention.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks for full clinical/remodeling effect.", + "tags": [] + }, + { + "key": "Half-life", + "val": "4-6 hours (but genomic effects last much longer). CYP3A4 metabolism.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: INSPRA/eplerenone Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Potassium-sparing Diuretic — Highly selective Mineralocorticoid Receptor Antagonist (MRA)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (25 mg, 50 mg). (Inspra)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 25 mg **OD**. Titrate up after 4 weeks to Max **50 mg OD** (dependent on K+ levels)." + }, + { + "label": "Key Indication Doses", + "value": "Heart Failure (Post-MI or Chronic): **PO** 25 mg **OD**. Titrate up after 4 weeks to Max **50 mg OD** (dependent on K+ levels). Renal Impairment: If **eGFR** 30-50, Max 25 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Eplerenone is the selective MRA of choice post-MI and in heart failure with proven mortality benefit, but hyperkalaemia risk mandates strict potassium monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Baseline K+ > 5.0 mmol/L, severe renal impairment (**eGFR** < 30). **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Electrolytes: Hyperkalemia (K+ > 5.5 mmol/L). Renal: Acute renal impairment/AKI. Endocrine: Gynecomastia and menstrual issues are practically zero (highly selective, no affinity for androgen/progesterone receptors)." + }, + { + "label": "Key Interactions", + "value": "Strong **CYP3A4** inhibitors (clarithromycin, itraconazole) massively increase eplerenone levels. Use is contraindicated. Potassium supplements, ACEi, ARBs (Hyperkalemia)." + }, + { + "label": "Monitoring", + "value": "**U&E** check at day 3, 1 week, 1 month, then 3-monthly. Adjust dose if K+ hits 5.0, withhold if K+ > 5.5. Monitor **BP** and assess for heart failure symptoms." + }, + { + "label": "Clinical Pearl", + "value": "Unlike Spironolactone, Eplerenone is a very weak blood pressure lowering agent. It is used almost exclusively for its anti-fibrotic, mortality-reducing properties in the heart." + } + ] + }, + { + "slug": "frusemide", + "name": "Frusemide", + "class": "Antihypertensive", + "subclass": "Loop Diuretic", + "category": "Cardiovascular - Diuretics", + "accent": "#0284c7", + "tag": "DIURETIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1000 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "Hypokalemia", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Dehydration", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent loop diuretic. The absolute cornerstone for fluid offloading in acute pulmonary oedema (APO) and congestive heart failure. Induces massive, rapid diuresis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1000 mg/day** (Only in severe end-stage renal failure. Standard max is usually 80-120 mg/day).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Potassium plummets rapidly. Proactive potassium replacement is almost always required during active diuresis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Frusemide is the most widely used loop diuretic for acute pulmonary oedema and fluid overload, but causes significant electrolyte depletion and ototoxicity at high IV doses.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Electrolytes", + "val": "CRITICAL — Hypokalemia, hypomagnesemia, hyponatremia, hypocalcemia.", + "tags": [] + }, + { + "key": "Renal", + "val": "HIGH — Acute Kidney Injury (AKI) due to intravascular volume depletion.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Ototoxicity (deafness/tinnitus) if pushed too rapidly via **IV** or at massive doses.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hyperuricemia (precipitates gout).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Pulmonary Oedema", + "val": "**IV** 20-50 mg STAT. May double dose and repeat if no diuresis within 1-2 hours.", + "tags": [] + }, + { + "key": "Heart Failure (Chronic)", + "val": "**PO** 20-80 mg **OD** or **BD** (usually morning and midday to prevent nocturia).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "Higher doses (e.g., 250 mg) are required as **eGFR** declines because the drug must reach the tubular lumen to work.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lasix, Urex", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (20 mg, 40 mg, 500 mg). Oral Liquid (10 mg/mL).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (20 mg/2 mL, 250 mg/25 mL) for **IV** or **IM** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Oedema associated with heart failure, hepatic cirrhosis, renal impairment.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Severe hypercalcemia (forces calcium excretion).", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "First-line for symptomatic fluid overload. Not used for primary hypertension unless severe CKD is present.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Anuria, severe volume depletion, hepatic coma. Avoid use in pregnancy or breastfeeding unless there are compelling medical reasons.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Frusemide should not be started in hepatic coma/precoma until underlying conditions are corrected." + } + }, + { + "key": "Allergy", + "val": "CONTRAINDICATED — Known hypersensitivity to frusemide or sulfonamides; sulfonamide cross-sensitivity may occur.", + "tags": [], + "patient": { + "factors": ["allergy-sulfa"], + "action": "contraindication", + "severity": "danger", + "note": "Frusemide is contraindicated in known frusemide/sulfonamide hypersensitivity." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C; use only for compelling medical reasons with fetal growth monitoring.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "danger", + "note": "Frusemide pregnancy row requires compelling indication and fetal growth monitoring rather than routine use." + } + }, + { + "key": "Lactation", + "val": "CONTRAINDICATED — Frusemide passes into breast milk and inhibits lactation; avoid breastfeeding while treated.", + "tags": [], + "patient": { + "factors": ["lactation"], + "action": "contraindication", + "severity": "danger", + "note": "Frusemide passes into breast milk and inhibits lactation; breastfeeding should be avoided while treated." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Triple Whammy", + "val": "CRITICAL — NSAIDs + ACEi/ARB + Frusemide = High risk of renal failure.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Enhances lithium toxicity. Increases risk of digoxin toxicity via hypokalemia.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Strict fluid balance chart (input/output) and daily **Weight**.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — Daily **U&E** during acute **IV** diuresis to catch hypokalemia early.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The IV to PO Switch", + "val": "Oral bioavailability of frusemide is roughly 50%. Therefore, 40 mg **PO** = 20 mg **IV**. Remember this when stepping down therapy for discharge.", + "tags": [] + }, + { + "key": "The Ototoxicity Rule", + "val": "Never push IV frusemide faster than 4 mg/minute. Rapid boluses of high doses cause permanent sensorineural hearing loss.", + "tags": [] + }, + { + "key": "The Ceiling Effect", + "val": "Loop diuretics have a ceiling effect. If 40 mg IV doesn't produce urine, giving another 40 mg won't work. You must double the dose to 80 mg to break the ceiling threshold.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits the Na+/K+/2Cl- cotransporter in the thick ascending limb of the loop of Henle. Blocks sodium reabsorption, causing profound water, potassium, and calcium loss.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins. **IV** 5 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "2-6 hours (hence the name 'Lasix' - lasts six hours).", + "tags": [] + }, + { + "key": "Half-life", + "val": "2 hours (Prolonged in renal/hepatic failure).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: LASIX/frusemide Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Loop Diuretic — Potent loop diuretic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (20 mg, 40 mg, 500 mg). Oral Liquid (10 mg/mL). (Lasix, Urex)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 20-50 mg STAT. May double dose and repeat if no diuresis within 1-2 hours. Max **1000 mg/day** (Only in severe end-stage renal failure. Standard max is usually 80-120 mg/day)." + }, + { + "label": "Key Indication Doses", + "value": "Acute Pulmonary Oedema: **IV** 20-50 mg STAT. May double dose and repeat if no diuresis within 1-2 hours. Heart Failure (Chronic): **PO** 20-80 mg **OD** or **BD** (usually morning and midday to prevent nocturia). Renal Impairment: Higher doses (e.g., 250 mg) are required as **eGFR** declines because the drug must reach the tubular lumen to work." + }, + { + "label": "Best Uses", + "value": "Frusemide is the most widely used loop diuretic for acute pulmonary oedema and fluid overload, but causes significant electrolyte depletion and ototoxicity at high IV doses." + }, + { + "label": "Avoid / Cautions", + "value": "Anuria, severe volume depletion, hepatic coma. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Electrolytes: Hypokalemia, hypomagnesemia, hyponatremia, hypocalcemia. Renal: Acute Kidney Injury (AKI) due to intravascular volume depletion. Neurological: Ototoxicity (deafness/tinnitus) if pushed too rapidly via **IV** or at massive doses. Metabolic: Hyperuricemia (precipitates gout)." + }, + { + "label": "Key Interactions", + "value": "NSAIDs + ACEi/ARB + Frusemide = High risk of renal failure. Enhances lithium toxicity. Increases risk of digoxin toxicity via hypokalemia." + }, + { + "label": "Monitoring", + "value": "Strict fluid balance chart (input/output) and daily **Weight**. Daily **U&E** during acute **IV** diuresis to catch hypokalemia early." + }, + { + "label": "Clinical Pearl", + "value": "Oral bioavailability of frusemide is roughly 50%. Therefore, 40 mg **PO** = 20 mg **IV**. Remember this when stepping down therapy for discharge." + } + ] + }, + { + "slug": "hydrochlorothiazide", + "name": "Hydrochlorothiazide", + "class": "Antihypertensive", + "subclass": "Thiazide Diuretic", + "category": "Cardiovascular - Diuretics", + "accent": "#0284c7", + "tag": "DIURETIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "50 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6–15 h", + "cls": "", + "flag": "" + }, + { + "label": "Hypokalemia", + "value": "RISK", + "cls": "warn", + "flag": "" + }, + { + "label": "Hyponatremia", + "value": "RISK", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Thiazide diuretic. Lowers blood pressure via mild diuresis and long-term direct vasodilation. Highly prone to causing metabolic disturbances.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **50 mg/day** (higher doses cause toxicity with no extra BP benefit).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Elderly patients are exceptionally prone to severe, life-threatening hyponatremia on this drug.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Hydrochlorothiazide is a cheap, effective first-line thiazide diuretic for hypertension, but causes hyponatraemia and hypokalaemia requiring regular electrolyte monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Electrolytes", + "val": "CRITICAL — Hyponatremia (can cause seizures/coma), Hypokalemia, Hypomagnesemia, HYPERcalcemia.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Hyperuricemia (triggers gout attacks), hyperglycemia, hyperlipidemia.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Photosensitivity, increased risk of non-melanoma skin cancers (SCC/BCC) with long-term use.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertension", + "val": "**PO** 12.5–25 mg **OD** (morning). Max **50 mg/day**.", + "tags": [] + }, + { + "key": "Heart Failure (Mild)", + "val": "**PO** 25–50 mg **OD**.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Strictly start at 12.5 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dithiazide, Atacand Plus (combo), Micardis Plus (combo)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (12.5 mg, 25 mg). Frequently combined with ACEi/ARBs.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension, mild heart failure.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Excellent combination agent with ACEi/ARBs, which counteract the thiazide-induced hypokalemia.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Anuria, severe sulfa allergy, refractory hypokalemia.", + "tags": [], + "patient": { + "factors": ["allergy-sulfa"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "HIGH — Becomes entirely ineffective if **eGFR** < 30 (requires switch to Loop diuretic).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "caution", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Hydrochlorothiazide becomes ineffective in severe renal impairment and should prompt review/switch to a loop diuretic." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Hydrochlorothiazide pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Lithium (thiazides reduce lithium clearance by 25-40%, causing severe toxicity).", + "tags": [] + }, + { + "key": "Triple Whammy", + "val": "CRITICAL — NSAIDs + ACEi + Thiazide.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and routine **U&E**. Monitor **BSL** in borderline diabetics. Check uric acid if joint pain occurs.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Monitor **BP**.", + "tags": [] + }, + { + "key": "Ocular", + "val": "WARNING — Stop and assess promptly if acute visual acuity reduction or eye pain occurs; hydrochlorothiazide can cause choroidal effusion, acute myopia, and secondary angle-closure glaucoma.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Calcium Difference", + "val": "Unlike loop diuretics (which waste calcium), thiazides *retain* calcium. This makes them excellent for hypertensive patients who also have osteoporosis or recurrent calcium kidney stones.", + "tags": [] + }, + { + "key": "Skin Cancer Risk", + "val": "Long-term HCTZ use is strongly linked to squamous cell skin cancer. Ensure elderly patients on chronic therapy have regular skin checks.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits Na+/Cl- cotransporter in the distal convoluted tubule. Promotes excretion of Na+, Cl-, and K+. Promotes REABSORPTION of Calcium.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "6-15 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: DITHIAZIDE/hydrochlorothiazide Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Thiazide Diuretic — Thiazide diuretic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (12.5 mg, 25 mg). Frequently combined with ACEi/ARBs. (Dithiazide, Atacand Plus (combo), Micardis Plus (combo))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 12.5–25 mg **OD** (morning). Max **50 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Hypertension: **PO** 12.5–25 mg **OD** (morning). Max **50 mg/day**. Heart Failure (Mild): **PO** 25–50 mg **OD**. Elderly / Frail: Strictly start at 12.5 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Hydrochlorothiazide is a cheap, effective first-line thiazide diuretic for hypertension, but causes hyponatraemia and hypokalaemia requiring regular electrolyte monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Anuria, severe sulfa allergy, refractory hypokalemia. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Electrolytes: Hyponatremia (can cause seizures/coma), Hypokalemia, Hypomagnesemia, HYPERcalcemia. Metabolic: Hyperuricemia (triggers gout attacks), hyperglycemia, hyperlipidemia. Dermatological: Photosensitivity, increased risk of non-melanoma skin cancers (SCC/BCC) with long-term use." + }, + { + "label": "Key Interactions", + "value": "Lithium (thiazides reduce lithium clearance by 25-40%, causing severe toxicity). NSAIDs + ACEi + Thiazide." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **U&E**. Monitor **BSL** in borderline diabetics. Check uric acid if joint pain occurs. Monitor **BP**." + }, + { + "label": "Clinical Pearl", + "value": "Unlike loop diuretics (which waste calcium), thiazides *retain* calcium. This makes them excellent for hypertensive patients who also have osteoporosis or recurrent calcium kidney stones." + } + ] + }, + { + "slug": "indapamide", + "name": "Indapamide", + "class": "Antihypertensive", + "subclass": "Thiazide-like Diuretic", + "category": "Cardiovascular - Diuretics", + "accent": "#0284c7", + "tag": "DIURETIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "2.5 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "14–24 h", + "cls": "", + "flag": "" + }, + { + "label": "Hyponatremia", + "value": "RISK", + "cls": "hi", + "flag": "" + }, + { + "label": "BP Efficacy", + "value": "HIGH", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Thiazide-like diuretic. Superior to hydrochlorothiazide for blood pressure lowering with slightly less metabolic disruption (glucose/lipids).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2.5 mg/day** (IR) or **1.5 mg/day** (SR).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Preferred over HCTZ in patients with metabolic syndrome or diabetes due to neutrality on glucose tolerance.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Indapamide is a thiazide-like diuretic with superior stroke prevention evidence (ADVANCE, HYVET), but carries the same electrolyte disturbance risks as conventional thiazides.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Electrolytes", + "val": "CRITICAL — Severe hyponatremia and hypokalemia.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "LOW — Mildly increases uric acid (gout risk), but largely neutral regarding blood glucose and lipids (unlike HCTZ).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Sulfa-allergy cross-reactivity, rare rash.", + "tags": [], + "patient": { + "factors": ["allergy-sulfa"], + "action": "caution", + "severity": "caution", + "note": "Indapamide is a sulfonamide derivative; sulfonamide allergy should prompt caution/review." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertension", + "val": "**PO** 1.25-2.5 mg (IR) **OD** morning. OR **PO** 1.5 mg (SR) **OD** morning.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Prefer 1.5 mg SR **OD** to minimise rapid electrolyte shifts.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Natrilix, Natrilix SR, Coversyl Plus (combo)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets IR (2.5 mg), Tablets SR (1.5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line diuretic option for hypertension. Supported by strong evidence in the elderly (HYVET trial).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal failure/anuria, hepatic coma/encephalopathy or severe hepatic impairment, severe sulfa allergy, hypokalaemia.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic", "allergy-sulfa"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Indapamide is contraindicated in severe renal failure/anuria, severe hepatic impairment/encephalopathy, and sulfonamide hypersensitivity." + } + }, + { + "key": "Renal Impairment", + "val": "HIGH — Loses diuretic efficacy at **eGFR** < 30.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "caution", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Indapamide loses diuretic efficacy in severe renal impairment; review therapy and consider alternatives." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Indapamide pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Lithium (decreases clearance, high toxicity risk).", + "tags": [] + }, + { + "key": "Triple Whammy", + "val": "CRITICAL — NSAIDs + ACEi + Indapamide.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **U&E** within 1-2 weeks of initiation. Elderly women are at massive risk of silent hyponatremia.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "MANDATORY — Monitor **BP**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Metabolic Advantage", + "val": "If a hypertensive patient has pre-diabetes or hyperlipidemia, switch them from HCTZ to Indapamide to protect their metabolic profile.", + "tags": [] + }, + { + "key": "The Elderly Trap", + "val": "Hyponatremia on indapamide can present as confusion, lethargy, or frequent falls in the elderly, mimicking dementia. Always check a U&E first.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits Na+/Cl- cotransporter in distal tubule. Also has direct smooth muscle relaxant properties, acting as a direct vasodilator.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h (SR).", + "tags": [] + }, + { + "key": "Half-life", + "val": "14-24 hours (Highly lipophilic, concentrates in vascular smooth muscle).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: NATRILIX/NATRILIX SR indapamide Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Thiazide-like Diuretic — Thiazide-like diuretic." + }, + { + "label": "Route / Formulation", + "value": "Tablets IR (2.5 mg), Tablets SR (1.5 mg). (Natrilix, Natrilix SR, Coversyl Plus (combo))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1.25-2.5 mg (IR) **OD** morning. OR **PO** 1.5 mg (SR) **OD** morning. Max **2.5 mg/day** (IR) or **1.5 mg/day** (SR)." + }, + { + "label": "Key Indication Doses", + "value": "Hypertension: **PO** 1.25-2.5 mg (IR) **OD** morning. OR **PO** 1.5 mg (SR) **OD** morning. Elderly / Frail: Prefer 1.5 mg SR **OD** to minimise rapid electrolyte shifts." + }, + { + "label": "Best Uses", + "value": "Indapamide is a thiazide-like diuretic with superior stroke prevention evidence (ADVANCE, HYVET), but carries the same electrolyte disturbance risks as conventional thiazides." + }, + { + "label": "Avoid / Cautions", + "value": "Severe hepatic failure (can precipitate hepatic encephalopathy), anuria, severe sulfa allergy. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Electrolytes: Severe hyponatremia and hypokalemia. Metabolic: Mildly increases uric acid (gout risk), but largely neutral regarding blood glucose and lipids (unlike HCTZ). Dermatological: Sulfa-allergy cross-reactivity, rare rash." + }, + { + "label": "Key Interactions", + "value": "Lithium (decreases clearance, high toxicity risk). NSAIDs + ACEi + Indapamide." + }, + { + "label": "Monitoring", + "value": "Check **U&E** within 1-2 weeks of initiation. Elderly women are at massive risk of silent hyponatremia. Monitor **BP**." + }, + { + "label": "Clinical Pearl", + "value": "If a hypertensive patient has pre-diabetes or hyperlipidemia, switch them from HCTZ to Indapamide to protect their metabolic profile." + } + ] + }, + { + "slug": "spironolactone", + "name": "Spironolactone", + "class": "Antihypertensive", + "subclass": "Potassium-sparing Diuretic", + "category": "Cardiovascular - Diuretics", + "accent": "#0284c7", + "tag": "MRA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1.4 h (Act: 16h)", + "cls": "", + "flag": "" + }, + { + "label": "Hyperkalemia", + "value": "HIGH RISK", + "cls": "hi", + "flag": "" + }, + { + "label": "Gynecomastia", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Aldosterone antagonist. Provides powerful mortality benefits in heart failure by preventing cardiac fibrosis, and is the drug of choice for cirrhotic ascites.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **50 mg/day** (Heart Failure) • Max **400 mg/day** (Ascites).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Potassium levels must be meticulously monitored, especially when combined with ACE inhibitors.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Spironolactone is the cornerstone MRA for heart failure and resistant hypertension with proven mortality benefit, but causes gynaecomastia in males and dangerous hyperkalaemia.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Electrolytes", + "val": "CRITICAL — Hyperkalemia. Hyponatremia.", + "tags": [] + }, + { + "key": "Endocrine", + "val": "HIGH — Gynecomastia (breast tissue growth in men), breast pain, menstrual irregularities (due to anti-androgenic effects).", + "tags": [] + }, + { + "key": "Renal", + "val": "MODERATE — AKI (especially if combined with NSAIDs).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "monitor", + "severity": "caution", + "note": "Existing row flags AKI risk, especially with NSAID co-prescribing; NSAID co-prescribing is not modeled as an allergy factor." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Heart Failure (HFrEF)", + "val": "**PO** 12.5–25 mg **OD**. Target Max **50 mg/day**.", + "tags": [] + }, + { + "key": "Ascites (Hepatic Cirrhosis)", + "val": "Start **PO** 100 mg **OD**. May titrate up to Max **400 mg/day** (often paired with frusemide in a 100:40 ratio).", + "tags": [] + }, + { + "key": "Resistant Hypertension", + "val": "**PO** 12.5-25 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Aldactone, Spiractin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (25 mg, 100 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "HFrEF, ascites due to cirrhosis, primary hyperaldosteronism, resistant hypertension.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Hormonal acne, PCOS, hirsutism.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Fourth pillar of HFrEF management. Gold standard for managing portal hypertension/ascites.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Baseline K+ > 5.0 mmol/L, severe renal impairment (**eGFR** < 30), Addison's disease.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Spironolactone is contraindicated/avoided in severe renal impairment because of hyperkalaemia risk." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3. Avoid due to potential feminisation of male fetus.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — ACEi, ARBs, potassium supplements (Massive hyperkalemia risk).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CAUTION — May increase half-life of Digoxin. Monitor **TDM**.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Strict **U&E** monitoring. Check K+ and creatinine at 1 week, 4 weeks, and after any dose changes.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor **Weight** in ascites/HF.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 100:40 Rule", + "val": "In liver cirrhosis with ascites, Spironolactone and Frusemide are typically prescribed in a 100 mg to 40 mg ratio. This precise balance maintains normokalemia while clearing the fluid.", + "tags": [] + }, + { + "key": "The Eplerenone Switch", + "val": "If a male patient develops painful gynecomastia on Spironolactone, do not stop MRA therapy entirely. Switch them to Eplerenone, which has zero affinity for androgen receptors.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive antagonist of the mineralocorticoid (aldosterone) receptor in the distal tubule. Prevents sodium reabsorption and potassium excretion. Prevents myocardial fibrosis.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Takes up to 48-72 hours to see diuretic effect.", + "tags": [] + }, + { + "key": "Duration", + "val": "48-72 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1.4 hours, but its active metabolite (canrenone) has a half-life of 16 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ALDACTONE/spironolactone Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Potassium-sparing Diuretic — Aldosterone antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (25 mg, 100 mg). (Aldactone, Spiractin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 12.5–25 mg **OD**. Target Max **50 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Heart Failure (HFrEF): **PO** 12.5–25 mg **OD**. Target Max **50 mg/day**. Ascites (Hepatic Cirrhosis): Start **PO** 100 mg **OD**. May titrate up to Max **400 mg/day** (often paired with frusemide in a 100:40 ratio). Resistant Hypertension: **PO** 12.5-25 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Spironolactone is the cornerstone MRA for heart failure and resistant hypertension with proven mortality benefit, but causes gynaecomastia in males and dangerous hyperkalaemia." + }, + { + "label": "Avoid / Cautions", + "value": "Baseline K+ > 5.0 mmol/L, severe renal impairment (**eGFR** < 30), Addison's disease. **Pregnancy** Category B3. Avoid due to potential feminisation of male fetus." + }, + { + "label": "Key Risks", + "value": "Electrolytes: Hyperkalemia. Hyponatremia. Endocrine: Gynecomastia (breast tissue growth in men), breast pain, menstrual irregularities (due to anti-androgenic effects). Renal: AKI (especially if combined with NSAIDs)." + }, + { + "label": "Key Interactions", + "value": "ACEi, ARBs, potassium supplements (Massive hyperkalemia risk). May increase half-life of Digoxin. Monitor **TDM**." + }, + { + "label": "Monitoring", + "value": "Strict **U&E** monitoring. Check K+ and creatinine at 1 week, 4 weeks, and after any dose changes. Monitor **Weight** in ascites/HF." + }, + { + "label": "Clinical Pearl", + "value": "In liver cirrhosis with ascites, Spironolactone and Frusemide are typically prescribed in a 100 mg to 40 mg ratio. This precise balance maintains normokalemia while clearing the fluid." + } + ] + }, + { + "slug": "atorvastatin", + "name": "Atorvastatin", + "class": "Lipid-Lowering", + "subclass": "HMG-CoA Reductase Inhibitor", + "category": "Cardiovascular - Lipid Lowering", + "accent": "#0284c7", + "tag": "STATIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "80 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "14 h", + "cls": "", + "flag": "" + }, + { + "label": "Myopathy", + "value": "RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Hepatic", + "value": "LFTs REQ", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent, long-acting statin. The cornerstone of primary and secondary prevention of atherosclerotic cardiovascular disease.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **80 mg/day** (Used for high-intensity secondary prevention post-MI/CVA).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Does not require evening dosing due to its long half-life. Monitor for muscle pain and dark urine.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Atorvastatin is the most prescribed statin with the broadest evidence base for cardiovascular risk reduction, but myalgia is common and rhabdomyolysis, though rare, requires vigilance.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Musculoskeletal", + "val": "HIGH — Myalgia (muscle aches), myopathy. CRITICAL — Rhabdomyolysis (muscle breakdown releasing myoglobin, causing renal failure).", + "tags": [] + }, + { + "key": "Hepatic", + "val": "MODERATE — Transaminitis (elevated ALT/AST).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Metabolic", + "val": "LOW — Mildly increases risk of new-onset Type 2 Diabetes.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Primary Prevention", + "val": "**PO** 10-20 mg **OD**.", + "tags": [] + }, + { + "key": "Secondary Prevention (Post-MI/Stroke)", + "val": "**PO** 40-80 mg **OD**. High-intensity therapy is mandatory unless contraindicated.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Consider starting at 10-20 mg **OD** due to increased myopathy risk.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lipitor, Lorstat", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg, 20 mg, 40 mg, 80 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypercholesterolemia, high CV risk, post-MI, post-CVA.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line lipid-lowering agent. Exhibits powerful pleiotropic anti-inflammatory effects that stabilize atherosclerotic plaques.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active liver disease, unexplained persistent transaminitis.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Existing absolute row names active or severe hepatic disease/failure; highlight when hepatic context is entered." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D (Cholesterol is essential for fetal development).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "Safe to use. Does not require renal dose adjustment.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "info", + "severity": "info", + "note": "Atorvastatin renal row is informational and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Metabolised exclusively by **CYP3A4**. Inhibitors (Clarithromycin, Grapefruit juice, Amiodarone, Diltiazem) massively increase Atorvastatin levels, precipitating rhabdomyolysis.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Gemfibrozil (Fibrate) blocks statin uptake, drastically increasing blood levels. Avoid combo.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and routine **Lipids** (to assess efficacy) and **LFTs**. Check CK (Creatine Kinase) if muscle pain occurs.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Ask about unexplained muscle pain, weakness, or brown/dark urine at every review.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Morning Rule", + "val": "Unlike older statins (Simvastatin/Pravastatin) which have short half-lives and must be taken strictly at night when cholesterol synthesis peaks, Atorvastatin's long half-life allows it to be taken at any time of day.", + "tags": [] + }, + { + "key": "The Macrolide Trap", + "val": "If you prescribe Clarithromycin to a patient on 80mg Atorvastatin, you will induce rhabdomyolysis. Withhold the statin for the duration of the antibiotic course.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive inhibitor of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis. Up-regulates LDL receptors on the liver, pulling LDL out of the blood.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Max lipid lowering seen at 2-4 weeks.", + "tags": [] + }, + { + "key": "Duration", + "val": "24-48 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "14 hours (Active metabolites have a half-life up to 30 hours).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: LIPITOR/atorvastatin Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "HMG-CoA Reductase Inhibitor — Highly potent, long-acting statin." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg, 20 mg, 40 mg, 80 mg). (Lipitor, Lorstat)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10-20 mg **OD**. Max **80 mg/day** (Used for high-intensity secondary prevention post-MI/CVA)." + }, + { + "label": "Key Indication Doses", + "value": "Primary Prevention: **PO** 10-20 mg **OD**. Secondary Prevention (Post-MI/Stroke): **PO** 40-80 mg **OD**. High-intensity therapy is mandatory unless contraindicated. Elderly / Frail: Consider starting at 10-20 mg **OD** due to increased myopathy risk." + }, + { + "label": "Best Uses", + "value": "Atorvastatin is the most prescribed statin with the broadest evidence base for cardiovascular risk reduction, but myalgia is common and rhabdomyolysis, though rare, requires vigilance." + }, + { + "label": "Avoid / Cautions", + "value": "Active liver disease, unexplained persistent transaminitis. **Pregnancy** Category D (Cholesterol is essential for fetal development)." + }, + { + "label": "Key Risks", + "value": "Musculoskeletal: Myalgia (muscle aches), myopathy. CRITICAL — Rhabdomyolysis (muscle breakdown releasing myoglobin, causing renal failure). Hepatic: Transaminitis (elevated ALT/AST). Metabolic: Mildly increases risk of new-onset Type 2 Diabetes." + }, + { + "label": "Key Interactions", + "value": "Metabolised exclusively by **CYP3A4**. Inhibitors (Clarithromycin, Grapefruit juice, Amiodarone, Diltiazem) massively increase Atorvastatin levels, precipitating rhabdomyolysis. Gemfibrozil (Fibrate) blocks statin uptake, drastically increasing blood levels. Avoid combo." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **Lipids** (to assess efficacy) and **LFTs**. Check CK (Creatine Kinase) if muscle pain occurs. Ask about unexplained muscle pain, weakness, or brown/dark urine at every review." + }, + { + "label": "Clinical Pearl", + "value": "Unlike older statins (Simvastatin/Pravastatin) which have short half-lives and must be taken strictly at night when cholesterol synthesis peaks, Atorvastatin's long half-life allows it to be taken at any time of day." + } + ] + }, + { + "slug": "ezetimibe", + "name": "Ezetimibe", + "class": "Lipid-Lowering", + "subclass": "Cholesterol Absorption Inhibitor", + "category": "Cardiovascular - Lipid Lowering", + "accent": "#0284c7", + "tag": "LIPID LOWERING", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "22 h", + "cls": "", + "flag": "" + }, + { + "label": "Myopathy", + "value": "LOW RISK", + "cls": "good", + "flag": "" + }, + { + "label": "Hepatic", + "value": "LFTs REQ", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Blocks the absorption of dietary and biliary cholesterol from the gut. Typically used as an add-on to statin therapy when targets aren't met.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day** (Flat dosing, no titration required).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Provides an extra 15-20% LDL reduction when added to a statin. Very well tolerated.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ezetimibe is the standard add-on to statins for additional LDL lowering when statins alone are insufficient, but provides modest benefit as monotherapy compared to statins.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "LOW — Diarrhea, abdominal pain.", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "LOW — Myalgia (far less than statins, but risk increases if given with a statin).", + "tags": [] + }, + { + "key": "Hepatic", + "val": "LOW — Mild transaminitis.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypercholesterolemia", + "val": "**PO** 10 mg **OD**. Used alone (if statin intolerant) or combined.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Ezetrol, Vytorin (combo), Atozet (combo)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for co-administration with statins or monotherapy in statin intolerance.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Primary hypercholesterolemia, familial hypercholesterolemia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Second-line lipid-lowering agent. Essential for patients failing to hit strict LDL targets (<1.4 mmol/L) post-MI on max statins.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active liver disease (if used in combination with a statin).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Existing absolute row names active or severe hepatic disease/failure; highlight when hepatic context is entered." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Ezetimibe pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CAUTION — Bile acid sequestrants (Cholestyramine) bind to Ezetimibe in the gut. Must be taken 2 hours before or 4 hours after.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CAUTION — Fibrates (increases risk of gallstones/cholelithiasis).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **Lipids** and **LFTs**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 6% Rule", + "val": "Doubling a statin dose (e.g., 40mg to 80mg) only yields a 6% further drop in LDL. Adding 10mg of Ezetimibe yields an additional 18% drop. Combo therapy is highly efficient.", + "tags": [] + }, + { + "key": "Not for Triglycerides", + "val": "Ezetimibe strictly lowers LDL cholesterol. It has virtually no effect on high triglycerides.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Localizes to the brush border of the small intestine and selectively inhibits the Niemann-Pick C1-Like 1 (NPC1L1) transporter, blocking cholesterol absorption.", + "tags": [] + }, + { + "key": "Onset", + "val": "Max effect at 2 weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "22 hours (Undergoes extensive enterohepatic recycling).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: EZETROL/ezetimibe Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Cholesterol Absorption Inhibitor — Blocks the absorption of dietary and biliary cholesterol from the gut." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg). (Ezetrol, Vytorin (combo), Atozet (combo))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10 mg **OD**. Used alone (if statin intolerant) or combined. Max **10 mg/day** (Flat dosing, no titration required)." + }, + { + "label": "Best Uses", + "value": "Ezetimibe is the standard add-on to statins for additional LDL lowering when statins alone are insufficient, but provides modest benefit as monotherapy compared to statins." + }, + { + "label": "Avoid / Cautions", + "value": "Active liver disease (if used in combination with a statin). **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Diarrhea, abdominal pain. Musculoskeletal: Myalgia (far less than statins, but risk increases if given with a statin). Hepatic: Mild transaminitis." + }, + { + "label": "Key Interactions", + "value": "Bile acid sequestrants (Cholestyramine) bind to Ezetimibe in the gut. Must be taken 2 hours before or 4 hours after. Fibrates (increases risk of gallstones/cholelithiasis)." + }, + { + "label": "Monitoring", + "value": "**Lipids** and **LFTs**." + }, + { + "label": "Clinical Pearl", + "value": "Doubling a statin dose (e.g., 40mg to 80mg) only yields a 6% further drop in LDL. Adding 10mg of Ezetimibe yields an additional 18% drop. Combo therapy is highly efficient." + } + ] + }, + { + "slug": "fenofibrate", + "name": "Fenofibrate", + "class": "Lipid-Lowering", + "subclass": "Fibrate", + "category": "Cardiovascular - Lipid Lowering", + "accent": "#0284c7", + "tag": "FIBRATE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "145 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "20 h", + "cls": "", + "flag": "" + }, + { + "label": "Myopathy", + "value": "HIGH w/ STATIN", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "PPAR-alpha agonist used primarily to lower extremely high triglycerides to prevent acute pancreatitis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **145 mg/day** (nanoparticle formulation) or **160 mg/day** (standard).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly toxic to muscles if combined with statins. If a fibrate must be used with a statin, Fenofibrate is safer than Gemfibrozil.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Fenofibrate is the fibrate of choice for hypertriglyceridaemia and diabetic dyslipidaemia, but increases creatinine (non-pathological) and carries myopathy risk when combined with statins.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Musculoskeletal", + "val": "HIGH — Myopathy, Rhabdomyolysis (exponentially increased if combined with a statin).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Cholelithiasis (gallstones), GI upset.", + "tags": [] + }, + { + "key": "Renal", + "val": "MODERATE — Can cause a reversible bump in serum creatinine.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Hypertriglyceridemia", + "val": "**PO** 145 mg **OD** (Lipidil) OR 160 mg **OD** (Lipidil EZ).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce dose to 48 mg/day if **eGFR** 30-59. Avoid entirely if **eGFR** < 30.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Fenofibrate requires dose reduction in moderate renal impairment and avoidance in severe renal impairment." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lipidil", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (48 mg, 145 mg). Take with food to improve absorption (unless nanoparticle formulation).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe hypertriglyceridemia (risk of pancreatitis), mixed dyslipidemia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Niche role. Used almost exclusively when Triglycerides are > 10 mmol/L to prevent pancreatitis, or in diabetic retinopathy.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal impairment, active liver disease, gallbladder disease.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Fenofibrate is contraindicated/avoided in severe renal impairment." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Fenofibrate pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Statins. The combo risks massive muscle breakdown. (Note: Gemfibrozil + Statin is an absolute contraindication. Fenofibrate + Statin is used with extreme caution).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Enhances the effect of Warfarin. Monitor INR closely.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **Lipids** (focusing on triglycerides), **LFTs**, **U&E** (creatinine), and baseline CK.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Warn patients to report unexplained muscle pain immediately.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Pancreatitis Threshold", + "val": "Statins are for heart attacks; Fibrates are for the pancreas. Fibrates only have a strong clinical role when TGs exceed 10 mmol/L, as this is the threshold for acute pancreatitis.", + "tags": [] + }, + { + "key": "Creatinine Bump", + "val": "Fenofibrate blocks the secretion of creatinine into the renal tubule, causing a false 'bump' in blood creatinine levels without actually causing true acute kidney injury.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Activates Peroxisome Proliferator-Activated Receptor alpha (PPAR-alpha), increasing lipolysis and elimination of triglyceride-rich particles from plasma.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "20 hours. Primarily renally excreted.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: LIPIDIL/fenofibrate Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Fibrate — PPAR-alpha agonist used primarily to lower extremely high triglycerides to prevent acute pancreatitis." + }, + { + "label": "Route / Formulation", + "value": "Tablets (48 mg, 145 mg). Take with food to improve absorption (unless nanoparticle formulation). (Lipidil)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 145 mg **OD** (Lipidil) OR 160 mg **OD** (Lipidil EZ). Max **145 mg/day** (nanoparticle formulation) or **160 mg/day** (standard)." + }, + { + "label": "Key Indication Doses", + "value": "Severe Hypertriglyceridemia: **PO** 145 mg **OD** (Lipidil) OR 160 mg **OD** (Lipidil EZ). Renal Impairment: Reduce dose to 48 mg/day if **eGFR** 30-59. Avoid entirely if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Fenofibrate is the fibrate of choice for hypertriglyceridaemia and diabetic dyslipidaemia, but increases creatinine (non-pathological) and carries myopathy risk when combined with statins." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal impairment, active liver disease, gallbladder disease. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Musculoskeletal: Myopathy, Rhabdomyolysis (exponentially increased if combined with a statin). Gastrointestinal: Cholelithiasis (gallstones), GI upset. Renal: Can cause a reversible bump in serum creatinine." + }, + { + "label": "Key Interactions", + "value": "Statins. The combo risks massive muscle breakdown. (Note: Gemfibrozil + Statin is an absolute contraindication. Fenofibrate + Statin is used with extreme caution). Enhances the effect of Warfarin. Monitor INR closely." + }, + { + "label": "Monitoring", + "value": "**Lipids** (focusing on triglycerides), **LFTs**, **U&E** (creatinine), and baseline CK. Warn patients to report unexplained muscle pain immediately." + }, + { + "label": "Clinical Pearl", + "value": "Statins are for heart attacks; Fibrates are for the pancreas. Fibrates only have a strong clinical role when TGs exceed 10 mmol/L, as this is the threshold for acute pancreatitis." + } + ] + }, + { + "slug": "rosuvastatin", + "name": "Rosuvastatin", + "class": "Lipid-Lowering", + "subclass": "HMG-CoA Reductase Inhibitor", + "category": "Cardiovascular - Lipid Lowering", + "accent": "#0284c7", + "tag": "STATIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "40 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "19 h", + "cls": "", + "flag": "" + }, + { + "label": "Myopathy", + "value": "RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The most potent statin available. Highly hydrophilic, meaning it penetrates muscle tissue less than atorvastatin, theoretically reducing myalgia risk.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **40 mg/day** (Do not exceed, high risk of proteinuria/renal toxicity at higher doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Unlike Atorvastatin, Rosuvastatin is renally cleared. High doses in severe CKD are contraindicated.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Rosuvastatin is the most potent statin for maximum LDL reduction, but requires dose adjustment in renal impairment and Asian populations due to increased myopathy risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Musculoskeletal", + "val": "HIGH — Myalgia, Rhabdomyolysis (Risk increases sharply at 40 mg dose).", + "tags": [] + }, + { + "key": "Renal", + "val": "MODERATE — Proteinuria, hematuria (specific to high-dose rosuvastatin).", + "tags": [] + }, + { + "key": "Hepatic", + "val": "MODERATE — Transaminitis.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Primary Prevention", + "val": "**PO** 5-10 mg **OD**.", + "tags": [] + }, + { + "key": "Secondary Prevention", + "val": "**PO** 20-40 mg **OD**.", + "tags": [] + }, + { + "key": "Asian Descent", + "val": "**PO** Max 20 mg **OD** (Genetically higher plasma exposures in this demographic).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** < 30, Max **20 mg/day**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Crestor", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg, 10 mg, 20 mg, 40 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe hypercholesterolemia, high CV risk, post-MI.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line high-intensity statin, particularly if a patient experiences muscle pain on Atorvastatin.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active liver disease.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Existing absolute row names active or severe hepatic disease/failure; highlight when hepatic context is entered." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Do not use 40 mg dose if **eGFR** < 30.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Rosuvastatin severe renal impairment should prompt dose restriction/review rather than automatic contraindication to all doses." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Much fewer CYP interactions than Atorvastatin/Simvastatin.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Cyclosporin (increases rosuvastatin levels 7-fold).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Statin Switch", + "val": "If a patient gets severe myalgia on Atorvastatin, stopping it, waiting for pain to clear, and trialing low-dose Rosuvastatin (5mg) is a highly successful clinical strategy due to its hydrophilicity.", + "tags": [] + }, + { + "key": "Dose Equivalency", + "val": "Rosuvastatin is roughly twice as potent as Atorvastatin. 20 mg Rosuvastatin = 40 mg Atorvastatin.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits HMG-CoA reductase. Highly hydrophilic (stays in liver, doesn't cross into muscle as easily).", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Max effect 2-4 weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "19 hours. Minimal CYP450 metabolism (mostly excreted unchanged via feces/urine).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: CRESTOR/rosuvastatin Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "HMG-CoA Reductase Inhibitor — The most potent statin available." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg, 10 mg, 20 mg, 40 mg). (Crestor)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5-10 mg **OD**. Max **40 mg/day** (Do not exceed, high risk of proteinuria/renal toxicity at higher doses)." + }, + { + "label": "Key Indication Doses", + "value": "Primary Prevention: **PO** 5-10 mg **OD**. Secondary Prevention: **PO** 20-40 mg **OD**. Asian Descent: **PO** Max 20 mg **OD** (Genetically higher plasma exposures in this demographic). Renal Impairment: If **eGFR** < 30, Max **20 mg/day**." + }, + { + "label": "Best Uses", + "value": "Rosuvastatin is the most potent statin for maximum LDL reduction, but requires dose adjustment in renal impairment and Asian populations due to increased myopathy risk." + }, + { + "label": "Avoid / Cautions", + "value": "Active liver disease. **Pregnancy** Category D." + }, + { + "label": "Key Risks", + "value": "Musculoskeletal: Myalgia, Rhabdomyolysis (Risk increases sharply at 40 mg dose). Renal: Proteinuria, hematuria (specific to high-dose rosuvastatin). Hepatic: Transaminitis." + }, + { + "label": "Key Interactions", + "value": "Much fewer CYP interactions than Atorvastatin/Simvastatin. Cyclosporin (increases rosuvastatin levels 7-fold)." + }, + { + "label": "Clinical Pearl", + "value": "If a patient gets severe myalgia on Atorvastatin, stopping it, waiting for pain to clear, and trialing low-dose Rosuvastatin (5mg) is a highly successful clinical strategy due to its hydrophilicity." + } + ] + }, + { + "slug": "clonidine", + "name": "Clonidine", + "class": "Adjunct", + "subclass": "Alpha-2 Agonist", + "category": "Cardiovascular - Vasodilators", + "accent": "#d97706", + "tag": "ALPHA-2", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "900 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12–16 h", + "cls": "", + "flag": "" + }, + { + "label": "Rebound HTN", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Central alpha-2 agonist that acts on the brainstem to turn off sympathetic outflow. Highly effective but fraught with severe rebound hypertension upon withdrawal.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **900 mcg/day** (given in divided doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never cease abruptly. Must be tapered over 7-10 days to avoid a fatal hypertensive crisis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Clonidine is a centrally-acting adjunct for resistant hypertension, opioid withdrawal, and ADHD, but abrupt cessation causes dangerous rebound hypertensive crises.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Sedation, drowsiness, depression, vivid dreams.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Dry mouth, severe constipation.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Bradycardia, orthostatic hypotension. CRITICAL — Rebound hypertensive crisis upon sudden cessation.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Resistant HTN", + "val": "**PO** 50–100 mcg **BD** to **TDS**. Max 900 mcg/day.", + "tags": [] + }, + { + "key": "Opiate/Alcohol Withdrawal", + "val": "**PO** 100-150 mcg **TDS** (Short-term, off-label).", + "tags": [] + }, + { + "key": "Agitation / Delirium", + "val": "**PO** 50 mcg **PRN** (Off-label).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Start at 25-50 mcg **BD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Catapres, Dixarit", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (100 mcg, 150 mcg), Dixarit (25 mcg). Note microgram dosing!", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (150 mcg/1 mL) for **IV** use (Rare, Specialist only).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertension, menopausal flushing, migraine prophylaxis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Withdrawal syndromes, severe acute agitation, ADHD in children.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Last-line for hypertension. Highly useful in toxicology/psychiatry for hyperadrenergic states.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe bradycardia, heart block (unless paced).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Clonidine pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + }, + { + "key": "Renal Impairment", + "val": "CAUTION — Dose reduction required if **CrCl** < 10.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "crcl": { + "lt": 10 + } + }, + "note": "Clonidine severe renal impairment should prompt dose reduction/review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Beta-blockers. Combining them massively increases the severity of rebound hypertension if Clonidine is missed/ceased (Beta-blockers leave alpha vasoconstriction unopposed).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive sedation with alcohol, benzos, and antipsychotics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Strict **BP** and **HR** monitoring. Ensure doses are not missed.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Rebound Crisis", + "val": "Missing even 1 or 2 doses can cause a massive catecholamine surge leading to stroke or MI. If a patient is NBM for surgery, Clonidine MUST be converted to IV/patch to prevent crisis.", + "tags": [] + }, + { + "key": "Microgram Warning", + "val": "Doses are in MICROGRAMS. A common prescribing error is writing '100 mg' instead of '100 mcg', which is a 1000-fold lethal overdose.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Stimulates central alpha-2 adrenoceptors in the brainstem, which inhibits sympathetic outflow, reducing HR, BP, and systemic vascular resistance.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "8-12 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12-16 hours (cleared approx 50% unchanged in urine).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: CATAPRES/clonidine Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha-2 Agonist — Central alpha-2 agonist that acts on the brainstem to turn off sympathetic outflow." + }, + { + "label": "Route / Formulation", + "value": "Tablets (100 mcg, 150 mcg), Dixarit (25 mcg). Note microgram dosing! (Catapres, Dixarit)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 50–100 mcg **BD** to **TDS**. Max 900 mcg/day." + }, + { + "label": "Key Indication Doses", + "value": "Resistant HTN: **PO** 50–100 mcg **BD** to **TDS**. Max 900 mcg/day. Opiate/Alcohol Withdrawal: **PO** 100-150 mcg **TDS** (Short-term, off-label). Agitation / Delirium: **PO** 50 mcg **PRN** (Off-label). Elderly / Frail: Start at 25-50 mcg **BD**." + }, + { + "label": "Best Uses", + "value": "Clonidine is a centrally-acting adjunct for resistant hypertension, opioid withdrawal, and ADHD, but abrupt cessation causes dangerous rebound hypertensive crises." + }, + { + "label": "Avoid / Cautions", + "value": "Severe bradycardia, heart block (unless paced). **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Neurological: Sedation, drowsiness, depression, vivid dreams. Gastrointestinal: Dry mouth, severe constipation. Cardiovascular: Bradycardia, orthostatic hypotension. CRITICAL — Rebound hypertensive crisis upon sudden cessation." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers. Combining them massively increases the severity of rebound hypertension if Clonidine is missed/ceased (Beta-blockers leave alpha vasoconstriction unopposed). Additive sedation with alcohol, benzos, and antipsychotics." + }, + { + "label": "Monitoring", + "value": "Strict **BP** and **HR** monitoring. Ensure doses are not missed. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Missing even 1 or 2 doses can cause a massive catecholamine surge leading to stroke or MI. If a patient is NBM for surgery, Clonidine MUST be converted to IV/patch to prevent crisis." + } + ] + }, + { + "slug": "hydralazine", + "name": "Hydralazine", + "class": "Vasodilator", + "subclass": "Direct Vasodilator", + "category": "Cardiovascular - Vasodilators", + "accent": "#0284c7", + "tag": "VASODILATOR", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "200 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1-2 h", + "cls": "", + "flag": "" + }, + { + "label": "Lupus-like", + "value": "RARE", + "cls": "warn", + "flag": "" + }, + { + "label": "Tachycardia", + "value": "REFLEX", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Direct-acting smooth muscle relaxant acting purely on arterioles. Powerful but triggers a massive reflex sympathetic response (tachycardia).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **200 mg/day** (to avoid autoimmune lupus-like syndrome).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Almost never used as monotherapy; must be paired with a beta-blocker to prevent reflex tachycardia and a diuretic to prevent fluid retention.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Hydralazine is a direct vasodilator safe in pregnancy and useful in heart failure (with nitrate), but causes reflex tachycardia and can trigger drug-induced lupus with chronic use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Reflex tachycardia, fluid retention, worsening angina.", + "tags": [] + }, + { + "key": "Immunological", + "val": "HIGH — Drug-induced systemic lupus erythematosus (DILE) at high doses >200mg.", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Headache, flushing (due to vasodilation).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertension (Chronic)", + "val": "**PO** 25 mg **BD**. Titrate to Max **100 mg BD** (200 mg/day).", + "tags": [] + }, + { + "key": "Hypertensive Emergency", + "val": "**IV** 5-10 mg slowly over 20 mins. Repeat every 20-30 mins PRN.", + "tags": [] + }, + { + "key": "Pre-eclampsia", + "val": "**IV** 5 mg boluses, titrated to response.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Apresoline", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (25 mg, 50 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (20 mg powder for reconstitution).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Moderate-to-severe hypertension, pre-eclampsia, HFrEF (in combination with nitrates).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Third or fourth-line agent for resistant hypertension. Major role in severe pre-eclampsia.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Ischaemic heart disease (monotherapy will cause reflex tachycardia and trigger an MI), aortic aneurysm, SLE.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C, but widely used for severe hypertension in pregnancy/pre-eclampsia when clinically indicated.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Hydralazine pregnancy row is a source-backed caution/use-with-monitoring row, not an automatic contraindication alert." + } + }, + { + "key": "Renal Impairment", + "val": "CAUTION — Increase dosing interval if **CrCl** < 30.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "crcl": { + "lt": 30 + } + }, + "note": "Hydralazine renal impairment should prompt dose interval adjustment/review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive hypotension with other vasodilators and anaesthetics.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "BENEFICIAL — Beta-blockers (blunt reflex tachycardia) and Diuretics (blunt fluid retention).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Continuous **BP** and **HR** monitoring if giving **IV**.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — Monitor **FBC** and ANA antibodies if using high doses long-term due to lupus risk.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Acetylator Phenotype", + "val": "Hydralazine metabolism depends on a patient's genetic acetylator status. 'Slow acetylators' accumulate the drug and are at high risk of drug-induced lupus.", + "tags": [] + }, + { + "key": "The Ischaemia Trap", + "val": "If you drop the afterload with hydralazine, the heart pumps faster to compensate. In a patient with coronary artery disease, this increased workload will cause ischemia unless a beta-blocker is on board.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Directly relaxes arteriolar smooth muscle (mechanisms likely involve NO generation/calcium handling). Reduces afterload.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-45 mins. **IV** 5-20 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "Up to 12 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-2 hours (Undergoes complex polymorphic acetylation in the liver).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: APRESOLINE/hydralazine Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Direct Vasodilator — Direct-acting smooth muscle relaxant acting purely on arterioles." + }, + { + "label": "Route / Formulation", + "value": "Tablets (25 mg, 50 mg). (Apresoline)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 25 mg **BD**. Titrate to Max **100 mg BD** (200 mg/day)." + }, + { + "label": "Key Indication Doses", + "value": "Hypertension (Chronic): **PO** 25 mg **BD**. Titrate to Max **100 mg BD** (200 mg/day). Hypertensive Emergency: **IV** 5-10 mg slowly over 20 mins. Repeat every 20-30 mins PRN. Pre-eclampsia: **IV** 5 mg boluses, titrated to response." + }, + { + "label": "Best Uses", + "value": "Hydralazine is a direct vasodilator safe in pregnancy and useful in heart failure (with nitrate), but causes reflex tachycardia and can trigger drug-induced lupus with chronic use." + }, + { + "label": "Avoid / Cautions", + "value": "Ischaemic heart disease (monotherapy will cause reflex tachycardia and trigger an MI), aortic aneurysm, SLE. **Pregnancy** Category C, but widely used and safe for pre-eclampsia." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Reflex tachycardia, fluid retention, worsening angina. Immunological: Drug-induced systemic lupus erythematosus (DILE) at high doses >200mg. Neurological: Headache, flushing (due to vasodilation)." + }, + { + "label": "Key Interactions", + "value": "Additive hypotension with other vasodilators and anaesthetics. BENEFICIAL — Beta-blockers (blunt reflex tachycardia) and Diuretics (blunt fluid retention)." + }, + { + "label": "Monitoring", + "value": "Continuous **BP** and **HR** monitoring if giving **IV**. Monitor **FBC** and ANA antibodies if using high doses long-term due to lupus risk." + }, + { + "label": "Clinical Pearl", + "value": "Hydralazine metabolism depends on a patient's genetic acetylator status. 'Slow acetylators' accumulate the drug and are at high risk of drug-induced lupus." + } + ] + }, + { + "slug": "prazosin", + "name": "Prazosin", + "class": "Adjunct", + "subclass": "Alpha-1 Antagonist", + "category": "Cardiovascular - Vasodilators", + "accent": "#0284c7", + "tag": "ALPHA-1", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2–3 h", + "cls": "", + "flag": "" + }, + { + "label": "First-Dose Drop", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "PTSD", + "value": "OFF-LABEL", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent, short-acting alpha-1 receptor antagonist. Causes massive vasodilation. Notorious for severe first-dose syncope.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day** (given in divided doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The first dose MUST be given at **NOCTE** while the patient is lying in bed to prevent collapse.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Prazosin is useful as an adjunct antihypertensive and for PTSD-related nightmares, but severe first-dose hypotension mandates starting at bedtime with a low dose.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — First-dose severe orthostatic hypotension (syncope). MODERATE — Palpitations, peripheral oedema.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Dizziness, drowsiness.", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "LOW — Priapism, retrograde ejaculation.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertension", + "val": "Start **PO** 0.5 mg **NOCTE** for 3-7 days. Maintenance 0.5-1 mg **BD** or **TDS**. Max 20 mg/day.", + "tags": [] + }, + { + "key": "PTSD / Nightmares (Off-Label)", + "val": "Start **PO** 0.5 mg **NOCTE**. Titrate up to 1-5 mg **NOCTE**.", + "tags": [] + }, + { + "key": "BPH", + "val": "**PO** 0.5 mg **BD** (though tamsulosin is superior).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Minipress", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (1 mg, 2 mg, 5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Resistant hypertension, Raynaud's.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "PTSD-associated nightmares, BPH.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Rarely used for BP monotherapy due to tachyphylaxis. Now heavily utilised in psychiatry for trauma nightmares.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of micturition syncope.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Prazosin pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + }, + { + "key": "Elderly / Frail", + "val": "CAUTION — Extreme risk of falls. Up-titrate at a glacial pace.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "caution", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Prazosin elderly/frail row should prompt fall-risk caution and slow titration rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — PDE-5 Inhibitors (Sildenafil/Viagra) cause severe, refractory hypotension if given within 4 hours of Prazosin.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive effects with beta-blockers and diuretics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Postural **BP** checks. Ensure the patient is educated to get up slowly from sitting/lying.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The First-Dose Phenomenon", + "val": "The first dose causes a profound loss of venomotor tone. If the patient stands up, blood pools in the legs, and they will faint. Must be taken strictly in bed.", + "tags": [] + }, + { + "key": "Psychiatric Utility", + "val": "Prazosin is a game-changer for severe PTSD nightmares because it crosses the blood-brain barrier and dampens the adrenaline surges that disrupt sleep.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive blockade of post-synaptic Alpha-1 adrenoceptors, preventing norepinephrine-induced vasoconstriction. Blocks CNS alpha-1 receptors involved in sleep arousal.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "10-12 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: MINIPRESS/prazosin Australian PI. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha-1 Antagonist — Highly potent, short-acting alpha-1 receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (1 mg, 2 mg, 5 mg). (Minipress)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 0.5 mg **NOCTE** for 3-7 days. Maintenance 0.5-1 mg **BD** or **TDS**. Max 20 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Hypertension: Start **PO** 0.5 mg **NOCTE** for 3-7 days. Maintenance 0.5-1 mg **BD** or **TDS**. Max 20 mg/day. PTSD / Nightmares (Off-Label): Start **PO** 0.5 mg **NOCTE**. Titrate up to 1-5 mg **NOCTE**. BPH: **PO** 0.5 mg **BD** (though tamsulosin is superior)." + }, + { + "label": "Best Uses", + "value": "Prazosin is useful as an adjunct antihypertensive and for PTSD-related nightmares, but severe first-dose hypotension mandates starting at bedtime with a low dose." + }, + { + "label": "Avoid / Cautions", + "value": "History of micturition syncope. **Pregnancy** Category B2." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: First-dose severe orthostatic hypotension (syncope). MODERATE — Palpitations, peripheral oedema. Neurological: Dizziness, drowsiness. Genitourinary: Priapism, retrograde ejaculation." + }, + { + "label": "Key Interactions", + "value": "PDE-5 Inhibitors (Sildenafil/Viagra) cause severe, refractory hypotension if given within 4 hours of Prazosin. Additive effects with beta-blockers and diuretics." + }, + { + "label": "Monitoring", + "value": "Postural **BP** checks. Ensure the patient is educated to get up slowly from sitting/lying. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "The first dose causes a profound loss of venomotor tone. If the patient stands up, blood pools in the legs, and they will faint. Must be taken strictly in bed." + } + ] + }, + { + "slug": "metaraminol", + "name": "Metaraminol", + "class": "Vasopressor", + "subclass": "Alpha Agonist", + "category": "Cardiovascular - Vasopressors & ICU", + "accent": "#e11d48", + "tag": "VASOPRESSOR", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Variable", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10 mins", + "cls": "warn", + "flag": "" + }, + { + "label": "Bradycardia", + "value": "REFLEX", + "cls": "warn", + "flag": "" + }, + { + "label": "Route", + "value": "IV PERIPHERAL", + "cls": "purple", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Synthetic vasopressor. Acts as a safer, peripheral alternative to noradrenaline for bridging hypotension on the ward or in theatre.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated to effect.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly prone to causing reflex bradycardia due to sudden spikes in blood pressure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Metaraminol is a rapid-acting vasopressor for acute intraoperative hypotension, but is a temporising measure only and must not replace definitive haemodynamic management.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Reflex bradycardia, ventricular arrhythmias, severe hypertension.", + "tags": [] + }, + { + "key": "Tissue", + "val": "MODERATE — Extravasation necrosis (less severe than noradrenaline but still dangerous).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypotension (Bolus)", + "val": "**IV** 0.5 - 1 mg push. Repeat as needed to achieve target BP.", + "tags": [] + }, + { + "key": "Hypotension (Infusion)", + "val": "**IV Infusion** Start at 1-2 mg/hour. Titrate to MAP > 65.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Aramine", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (10 mg/1 mL). Often pre-drawn in 10 mL syringes (1 mg/mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply only.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute hypotension (e.g., post-anaesthesia, epidural, or bridging to ICU).", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "The go-to 'ward' or 'theatre' vasopressor because it is significantly safer to run through a peripheral cannula than noradrenaline.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Uncorrected hypovolemia, concurrent MAOI use.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Metaraminol pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs (e.g., phenelzine). Since metaraminol releases endogenous norepinephrine, MAOIs prevent its breakdown, causing lethal hypertensive crisis.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Continuous or frequent **BP** monitoring. Ensure the peripheral IV cannula is patent and flushes easily.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Vagal Reflex", + "val": "When Metaraminol spikes the blood pressure, baroreceptors in the aortic arch trigger massive vagal tone, slowing the heart. Anticipate reflex bradycardia.", + "tags": [] + }, + { + "key": "Depletion Trap", + "val": "Because its mechanism relies partially on squeezing out existing norepinephrine stores, it may fail to work (tachyphylaxis) in patients who are severely depleted, such as in late-stage septic shock.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Direct alpha-1 agonist (vasoconstriction) and indirect action by triggering norepinephrine release from sympathetic vesicles.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 1-2 minutes.", + "tags": [] + }, + { + "key": "Duration", + "val": "20-60 minutes.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10 minutes.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ARAMINE/metaraminol Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha Agonist — Synthetic vasopressor." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (10 mg/1 mL). Often pre-drawn in 10 mL syringes (1 mg/mL). (Aramine)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 0.5 - 1 mg push. Repeat as needed to achieve target BP. Titrated to effect." + }, + { + "label": "Key Indication Doses", + "value": "Hypotension (Bolus): **IV** 0.5 - 1 mg push. Repeat as needed to achieve target BP. Hypotension (Infusion): **IV Infusion** Start at 1-2 mg/hour. Titrate to MAP > 65." + }, + { + "label": "Best Uses", + "value": "Metaraminol is a rapid-acting vasopressor for acute intraoperative hypotension, but is a temporising measure only and must not replace definitive haemodynamic management." + }, + { + "label": "Avoid / Cautions", + "value": "Uncorrected hypovolemia, concurrent MAOI use. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Reflex bradycardia, ventricular arrhythmias, severe hypertension. Tissue: Extravasation necrosis (less severe than noradrenaline but still dangerous)." + }, + { + "label": "Key Interactions", + "value": "MAOIs (e.g., phenelzine). Since metaraminol releases endogenous norepinephrine, MAOIs prevent its breakdown, causing lethal hypertensive crisis." + }, + { + "label": "Monitoring", + "value": "Continuous or frequent **BP** monitoring. Ensure the peripheral IV cannula is patent and flushes easily." + }, + { + "label": "Clinical Pearl", + "value": "When Metaraminol spikes the blood pressure, baroreceptors in the aortic arch trigger massive vagal tone, slowing the heart. Anticipate reflex bradycardia." + } + ] + }, + { + "slug": "noradrenaline", + "name": "Noradrenaline", + "class": "Vasopressor", + "subclass": "Alpha/Beta Agonist", + "category": "Cardiovascular - Vasopressors & ICU", + "accent": "#e11d48", + "tag": "VASOPRESSOR", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Variable", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2.5 mins", + "cls": "warn", + "flag": "" + }, + { + "label": "Ischaemia", + "value": "RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Route", + "value": "IV CENTRAL", + "cls": "purple", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The gold-standard vasopressor. Potent alpha-1 agonist causing intense vasoconstriction to elevate blood pressure in shock.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max varies entirely by clinical response. Escalating doses reflect profound shock state.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Requires a central venous catheter (CVC) due to the severe risk of tissue necrosis if extravasation occurs via a peripheral line.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Noradrenaline is the first-line vasopressor for septic shock and ICU haemodynamic support, but must be given via central line as peripheral extravasation causes tissue necrosis.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Severe hypertension, reflex bradycardia, peripheral and mesenteric ischaemia, arrhythmias.", + "tags": [] + }, + { + "key": "Tissue", + "val": "CRITICAL — Extravasation causes profound local vasoconstriction, leading to gangrene and limb loss.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Distributive Shock (Sepsis)", + "val": "**IV Infusion** Start at 0.05 - 0.1 mcg/kg/min via CVC. Titrate strictly to target MAP (usually > 65 mmHg).", + "tags": [] + }, + { + "key": "Peripheral Emergency", + "val": "In extreme emergencies, dilute preparations can be run peripherally for a very short time while awaiting CVC insertion.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Levophed", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (4 mg/4 mL or 8 mg/8 mL) requiring dilution in D5W or Normal Saline.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Restricted. ICU/OT supply only.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Septic shock, cardiogenic shock, profound hypotension.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line vasopressor in ICU for almost all forms of shock.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Hypovolemia (must restore fluid volume first), mesenteric/peripheral vascular thrombosis.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3. Reduces placental perfusion.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Noradrenaline pregnancy row is a source-backed caution for emergency use and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs and TCAs massively potentiate the pressor effects, leading to hypertensive crisis.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Intra-arterial **BP** line. Strict IV site checks if run peripherally.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor ABGs (lactate clearance).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Antidote", + "val": "If noradrenaline extravasates into tissue, immediately infiltrate the area with Phentolamine (an alpha-blocker) to reverse the severe vasoconstriction and save the limb.", + "tags": [] + }, + { + "key": "Fill the Tank First", + "val": "Vasopressors squeeze the blood vessels. If the patient is empty (hypovolemic), squeezing empty vessels causes ischaemia and fails to improve organ perfusion. Resuscitate with IV fluids first.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Strong alpha-1 adrenoceptor agonist (vasoconstriction) and mild beta-1 agonist (mild increase in cardiac output and HR).", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Duration", + "val": "1-2 minutes post-infusion.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2.5 minutes (Rapidly metabolised by COMT and MAO).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: Noradrenaline Medsurge Australian PI/CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha/Beta Agonist — The gold-standard vasopressor." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (4 mg/4 mL or 8 mg/8 mL) requiring dilution in D5W or Normal Saline. (Levophed)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV Infusion** Start at 0.05 - 0.1 mcg/kg/min via CVC. Titrate strictly to target MAP (usually > 65 mmHg). Max varies entirely by clinical response. Escalating doses reflect profound shock state." + }, + { + "label": "Key Indication Doses", + "value": "Distributive Shock (Sepsis): **IV Infusion** Start at 0.05 - 0.1 mcg/kg/min via CVC. Titrate strictly to target MAP (usually > 65 mmHg). Peripheral Emergency: In extreme emergencies, dilute preparations can be run peripherally for a very short time while awaiting CVC insertion." + }, + { + "label": "Best Uses", + "value": "Noradrenaline is the first-line vasopressor for septic shock and ICU haemodynamic support, but must be given via central line as peripheral extravasation causes tissue necrosis." + }, + { + "label": "Avoid / Cautions", + "value": "Hypovolemia (must restore fluid volume first), mesenteric/peripheral vascular thrombosis. **Pregnancy** Category B3. Reduces placental perfusion." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Severe hypertension, reflex bradycardia, peripheral and mesenteric ischaemia, arrhythmias. Tissue: Extravasation causes profound local vasoconstriction, leading to gangrene and limb loss." + }, + { + "label": "Key Interactions", + "value": "MAOIs and TCAs massively potentiate the pressor effects, leading to hypertensive crisis." + }, + { + "label": "Monitoring", + "value": "Intra-arterial **BP** line. Strict IV site checks if run peripherally. Monitor ABGs (lactate clearance)." + }, + { + "label": "Clinical Pearl", + "value": "If noradrenaline extravasates into tissue, immediately infiltrate the area with Phentolamine (an alpha-blocker) to reverse the severe vasoconstriction and save the limb." + } + ] + }, + { + "slug": "sodium-nitroprusside", + "name": "Sodium nitroprusside", + "class": "Vasodilator", + "subclass": "Direct Vasodilator", + "category": "Cardiovascular - Vasopressors & ICU", + "accent": "#e11d48", + "tag": "VASODILATOR", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mcg/kg/min", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "<2 mins", + "cls": "warn", + "flag": "" + }, + { + "label": "Cyanide Tox", + "value": "RISK", + "cls": "hi", + "flag": "" + }, + { + "label": "Route", + "value": "IV ONLY", + "cls": "purple", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-short acting, intensely potent venous and arterial vasodilator. Breaks down in the blood to release Nitric Oxide and Cyanide.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mcg/kg/min** (Infusions > 2 mcg/kg/min carry high cyanide toxicity risk over time).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "ICU/OT medication only. Requires an arterial line for continuous beat-to-beat blood pressure monitoring.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Sodium nitroprusside is the most potent IV vasodilator for hypertensive emergencies, but requires arterial line monitoring and carries the risk of fatal cyanide toxicity with prolonged use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Profound, irreversible hypotension if overdosed. 'Coronary steal' syndrome in IHD.", + "tags": [] + }, + { + "key": "Toxicology", + "val": "CRITICAL — Cyanide toxicity (metabolic acidosis, coma, almond breath) and Thiocyanate toxicity (delirium, seizures, tinnitus).", + "tags": [] + }, + { + "key": "Haematological", + "val": "MODERATE — Methaemoglobinaemia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypertensive Crisis / Acute Heart Failure", + "val": "**IV Infusion** Start 0.25–0.5 mcg/kg/min. Titrate strictly to BP response. Max **10 mcg/kg/min** (for maximum 10 minutes).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "Avoid prolonged use; highly sensitive to thiocyanate accumulation.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nipride", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (50 mg). Must be protected from light (wrapped in foil/opaque bag).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Restricted. Hospital supply only.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypertensive emergencies, controlled hypotension during surgery, acute heart failure.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "When instant, rapidly titratable, profound afterload/preload reduction is required.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Compensatory hypertension (e.g., severe A-V shunting or coarctation of the aorta), uncorrected hypovolemia, severe vitamin B12 deficiency.", + "tags": [] + }, + { + "key": "Hepatic / Renal", + "val": "CRITICAL — Cyanide is cleared by the liver; Thiocyanate is cleared by the kidneys. Avoid in severe organ failure.", + "tags": [], + "patient": { + "factors": ["hepatic", "renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Sodium nitroprusside cyanide/thiocyanate toxicity risk is increased in severe hepatic or renal impairment." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. Fetal cyanide toxicity.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — PDE5 inhibitors (e.g., Sildenafil) cause catastrophic hypotension.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Intra-arterial **BP** line. Observe for signs of cyanide toxicity (unexplained metabolic acidosis, rising lactate).", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — Frequent ABGs (lactate, pH). Monitor thiocyanate levels if infusion lasts > 48 hours.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Light Sensitivity", + "val": "The IV bag and lines MUST be wrapped in foil or black plastic. Exposure to light breaks the drug down into cyanide directly in the bag.", + "tags": [] + }, + { + "key": "The Cyanide Antidote", + "val": "If cyanide toxicity occurs, cease infusion immediately and administer Sodium Thiosulfate or Hydroxocobalamin to bind the free cyanide.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Interacts with oxyhaemoglobin to immediately release Nitric Oxide (NO) and cyanide ions. NO triggers cGMP, relaxing vascular smooth muscle.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate (<30 seconds).", + "tags": [] + }, + { + "key": "Duration", + "val": "1-10 minutes post-infusion.", + "tags": [] + }, + { + "key": "Half-life", + "val": "< 2 minutes.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: Sodium nitroprusside Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Direct Vasodilator — Ultra-short acting, intensely potent venous and arterial vasodilator." + }, + { + "label": "Route / Formulation", + "value": "Ampoule (50 mg). Must be protected from light (wrapped in foil/opaque bag). (Nipride)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV Infusion** Start 0.25–0.5 mcg/kg/min. Titrate strictly to BP response. Max **10 mcg/kg/min** (for maximum 10 minutes)." + }, + { + "label": "Key Indication Doses", + "value": "Hypertensive Crisis / Acute Heart Failure: **IV Infusion** Start 0.25–0.5 mcg/kg/min. Titrate strictly to BP response. Max **10 mcg/kg/min** (for maximum 10 minutes). Renal Impairment: Avoid prolonged use; highly sensitive to thiocyanate accumulation." + }, + { + "label": "Best Uses", + "value": "Sodium nitroprusside is the most potent IV vasodilator for hypertensive emergencies, but requires arterial line monitoring and carries the risk of fatal cyanide toxicity with prolonged use." + }, + { + "label": "Avoid / Cautions", + "value": "Compensatory hypertension (e.g., severe A-V shunting or coarctation of the aorta), uncorrected hypovolemia, severe vitamin B12 deficiency. **Pregnancy** Category C. Fetal cyanide toxicity." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Profound, irreversible hypotension if overdosed. 'Coronary steal' syndrome in IHD. Toxicology: Cyanide toxicity (metabolic acidosis, coma, almond breath) and Thiocyanate toxicity (delirium, seizures, tinnitus). Haematological: Methaemoglobinaemia." + }, + { + "label": "Key Interactions", + "value": "PDE5 inhibitors (e.g., Sildenafil) cause catastrophic hypotension." + }, + { + "label": "Monitoring", + "value": "Intra-arterial **BP** line. Observe for signs of cyanide toxicity (unexplained metabolic acidosis, rising lactate). Frequent ABGs (lactate, pH). Monitor thiocyanate levels if infusion lasts > 48 hours." + }, + { + "label": "Clinical Pearl", + "value": "The IV bag and lines MUST be wrapped in foil or black plastic. Exposure to light breaks the drug down into cyanide directly in the bag." + } + ] + }, + { + "slug": "vasopressin", + "name": "Vasopressin", + "class": "Vasopressor", + "subclass": "ADH Analog", + "category": "Cardiovascular - Vasopressors & ICU", + "accent": "#e11d48", + "tag": "VASOPRESSOR", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "0.04 units/min", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10-20 mins", + "cls": "", + "flag": "" + }, + { + "label": "Ischaemia", + "value": "SPLANCHNIC RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Sepsis", + "value": "2ND LINE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Synthetic Antidiuretic Hormone (ADH). Potent, non-catecholamine vasopressor. Works completely independently of adrenergic receptors, making it brilliant for refractory, acidotic septic shock.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **0.04 units/min** (Higher doses cause catastrophic bowel/digit ischemia).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Given at a flat, non-titrated rate (usually 0.04 units/min) as an 'add-on' to Noradrenaline to spare massive catecholamine doses.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Vasopressin is a second-line vasopressor for septic shock and cardiac arrest (non-shockable rhythms), but causes peripheral ischaemia including digital gangrene and must be infused through central access.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Severe splanchnic (gut) ischaemia, digital necrosis (fingers/toes falling off), coronary vasospasm, reflex bradycardia.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Hyponatremia (due to massive free water retention via V2 receptors), water intoxication.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Vasodilatory / Septic Shock", + "val": "**IV Infusion** 0.01 to 0.04 units/minute (Flat rate, rarely titrated). Run via Central Line.", + "tags": [] + }, + { + "key": "Post-Cardiotomy Vasoplegia", + "val": "**IV Infusion** 0.01 to 0.06 units/minute.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Pitressin", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (20 units/1 mL). MUST be heavily diluted in Normal Saline/D5W.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital ICU/OT supply only.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Refractory septic shock, vasoplegic shock post-cardiac surgery, diabetes insipidus.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Second-line vasopressor added when Noradrenaline doses are climbing dangerously high, or when profound acidosis renders Noradrenaline useless.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Uncorrected hypovolemia. Extreme caution in severe coronary artery disease (can cause myocardial infarction).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Vasopressin pregnancy row is a source-backed caution and should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive profound vasoconstriction with Noradrenaline (though intentionally used together for synergy).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Intra-arterial **BP** line. Assess fingers, toes, and bowel function strictly for signs of ischemic necrosis.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor **U&E** (sodium) and ABGs (Lactate tracking for gut ischemia).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Acidosis Bypass", + "val": "When a patient is in severe septic shock, their blood becomes highly acidic. Acidosis physically warps the alpha-1 receptors, causing Noradrenaline to bounce off and fail. Vasopressin uses the V1 receptor, which is immune to acidosis, instantly restoring blood pressure.", + "tags": [] + }, + { + "key": "The Flat Rate", + "val": "Unlike Noradrenaline which is titrated up and down constantly, Vasopressin is usually just turned ON at 0.04 units/min and left alone as a baseline 'floor' to support the pressure.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Directly agonizes V1 receptors on vascular smooth muscle, causing profound peripheral vasoconstriction. Agonizes V2 receptors in the kidney, causing water reabsorption. Bypasses the alpha-1 receptor entirely.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 1-3 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "10-30 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10-20 minutes. Cleared by tissue peptidases and kidneys.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: PITRESSIN/argipressin Australian PI and Safer Care Victoria vasopressin guidance. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "ADH Analog — Synthetic Antidiuretic Hormone (ADH)." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (20 units/1 mL). MUST be heavily diluted in Normal Saline/D5W. (Pitressin)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV Infusion** 0.01 to 0.04 units/minute (Flat rate, rarely titrated). Run via Central Line. Max **0.04 units/min** (Higher doses cause catastrophic bowel/digit ischemia)." + }, + { + "label": "Key Indication Doses", + "value": "Vasodilatory / Septic Shock: **IV Infusion** 0.01 to 0.04 units/minute (Flat rate, rarely titrated). Run via Central Line. Post-Cardiotomy Vasoplegia: **IV Infusion** 0.01 to 0.06 units/minute." + }, + { + "label": "Best Uses", + "value": "Vasopressin is a second-line vasopressor for septic shock and cardiac arrest (non-shockable rhythms), but causes peripheral ischaemia including digital gangrene and must be infused through central access." + }, + { + "label": "Avoid / Cautions", + "value": "Uncorrected hypovolemia. Extreme caution in severe coronary artery disease (can cause myocardial infarction). **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Severe splanchnic (gut) ischaemia, digital necrosis (fingers/toes falling off), coronary vasospasm, reflex bradycardia. Metabolic: Hyponatremia (due to massive free water retention via V2 receptors), water intoxication." + }, + { + "label": "Key Interactions", + "value": "Additive profound vasoconstriction with Noradrenaline (though intentionally used together for synergy)." + }, + { + "label": "Monitoring", + "value": "Intra-arterial **BP** line. Assess fingers, toes, and bowel function strictly for signs of ischemic necrosis. Monitor **U&E** (sodium) and ABGs (Lactate tracking for gut ischemia)." + }, + { + "label": "Clinical Pearl", + "value": "When a patient is in severe septic shock, their blood becomes highly acidic. Acidosis physically warps the alpha-1 receptors, causing Noradrenaline to bounce off and fail. Vasopressin uses the V1 receptor, which is immune to acidosis, instantly restoring blood pressure." + } + ] + }, + { + "slug": "betamethasone", + "name": "Betamethasone", + "class": "Steroid", + "subclass": "Topical Glucocorticoid", + "category": "Dermatology - Topical Corticosteroids", + "accent": "#475569", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Potency", + "value": "POTENT", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Max Use", + "value": "<=4 WEEKS", + "cls": "warn", + "flag": "" + }, + { + "label": "Face Safe", + "value": "NEVER", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Systemic Abs.", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent topical corticosteroid. Highly effective for thick, lichenified, or severely inflamed skin conditions. Can cause severe local tissue damage if abused.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Apply a thin film once or twice daily; do not use continuously for more than 4 weeks without specialist review.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "If applied to large body surface areas or placed under occlusion (wraps/bandages), enough drug is absorbed to suppress the adrenal glands systemically.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Betamethasone is a potent topical corticosteroid for severe eczema and inflammatory dermatoses, but must not be used on the face or flexures due to skin atrophy and telangiectasia risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Dermatological", + "val": "HIGH — Rapid skin atrophy (paper-thin skin that tears easily), permanent striae, prominent telangiectasia, masking of fungal infections (Tinea Incognito).", + "tags": [] + }, + { + "key": "Endocrine", + "val": "MODERATE — HPA axis suppression (Cushingoid features) if used over large areas for months.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Dermatoses / Psoriasis", + "val": "**Topical** Apply **OD** to **BD** to the body or limbs.", + "tags": [] + }, + { + "key": "Scalp Psoriasis", + "val": "**Topical** Apply scalp lotion/drops **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Diprosone, Eleuphrat, Betnovate", + "tags": [] + }, + { + "key": "Topical Routes", + "val": "Cream/Ointment 0.05% (Diprosone). Scalp lotion. (Diprosone OV is *Optimised Vehicle*, making it ultra-potent).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe eczema, psoriasis, lichen planus, discoid lupus.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Third-line step-up. Used for thick, scaly plaques where weaker steroids cannot penetrate.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Hypersensitivity, viral skin infections such as cold sores/shingles/chickenpox, cutaneous tuberculosis, acne rosacea, and untreated bacterial/fungal skin infection. Avoid face, groin, axillae, ulcers, occlusion, or large areas unless specifically directed.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — Use in pregnancy only if clearly needed; use the lowest effective potency, smallest amount, and shortest duration.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Topical betamethasone in pregnancy should use the lowest effective amount for the shortest duration." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "NONE — Significant systemic interactions are rare unless heavily abused.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Apply a thin film only. Review if more than 4 weeks are needed; avoid occlusion, large areas, face/flexures, and untreated infection because systemic absorption and skin atrophy risk increase.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Tinea Incognito", + "val": "If you prescribe Betamethasone for a 'rash' that is actually a fungal infection, the steroid turns off the immune system's redness/itching, making the rash *look* better. Meanwhile, the fungus grows wildly out of control into deep tissues (Tinea Incognito). Always rule out fungus.", + "tags": [] + }, + { + "key": "The OV Difference", + "val": "Diprosone OV (Optimised Vehicle) uses propylene glycol to massively enhance penetration. It is significantly stronger than standard Diprosone cream, placing it near the 'ultra-potent' class.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Highly potent fluorinated glucocorticoid. Induces powerful local vasoconstriction and inflammatory suppression.", + "tags": [] + }, + { + "key": "Onset", + "val": "1-3 days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Local action. Systemic absorption can be 1-5% (significant given the high potency).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: DIPROSONE/DIPROSONE OV betamethasone Australian PI/CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Topical Glucocorticoid — Potent topical corticosteroid." + }, + { + "label": "Route / Formulation", + "value": "Cream/Ointment 0.05% (Diprosone). Scalp lotion. (Diprosone OV is *Optimised Vehicle*, making it ultra-potent). (Diprosone, Eleuphrat, Betnovate)" + }, + { + "label": "Usual Dose & Max", + "value": "**Topical** Apply **OD** to **BD** to the body or limbs. Apply a thin layer **OD** or **BD** for max 2 weeks." + }, + { + "label": "Key Indication Doses", + "value": "Severe Dermatoses / Psoriasis: **Topical** Apply **OD** to **BD** to the body or limbs. Scalp Psoriasis: **Topical** Apply scalp lotion/drops **OD**." + }, + { + "label": "Best Uses", + "value": "Betamethasone is a potent topical corticosteroid for severe eczema and inflammatory dermatoses, but must not be used on the face or flexures due to skin atrophy and telangiectasia risk." + }, + { + "label": "Avoid / Cautions", + "value": "Face, groin, axillae. Untreated infections. **Pregnancy** Category C. (Mild/moderate steroids preferred, though topical Betamethasone is often required and used cautiously)." + }, + { + "label": "Key Risks", + "value": "Dermatological: Rapid skin atrophy (paper-thin skin that tears easily), permanent striae, prominent telangiectasia, masking of fungal infections (Tinea Incognito). Endocrine: HPA axis suppression (Cushingoid features) if used over large areas for months." + }, + { + "label": "Key Interactions", + "value": "NONE — Significant systemic interactions are rare unless heavily abused." + }, + { + "label": "Monitoring", + "value": "Teach the patient to use 'pulse therapy' (e.g., use for 5 days, take 2 days off) to prevent tachyphylaxis (loss of efficacy) and skin thinning." + }, + { + "label": "Clinical Pearl", + "value": "If you prescribe Betamethasone for a 'rash' that is actually a fungal infection, the steroid turns off the immune system's redness/itching, making the rash *look* better. Meanwhile, the fungus grows wildly out of control into deep tissues (Tinea Incognito). Always rule out fungus." + } + ] + }, + { + "slug": "clobetasol", + "name": "Clobetasol", + "class": "Steroid", + "subclass": "Topical Glucocorticoid", + "category": "Dermatology - Topical Corticosteroids", + "accent": "#475569", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Potency", + "value": "ULTRA-POTENT", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Max Dose", + "value": "14 g / WEEK", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Max Use", + "value": "<=2 WEEKS", + "cls": "warn", + "flag": "" + }, + { + "label": "Adrenal Supp.", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-potent topical corticosteroid (Class I / Super-Potent). Up to 600 times stronger than hydrocortisone. The absolute strongest topical steroid in human medicine.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Apply sparingly 1-2 times daily for a maximum of 2 consecutive weeks; do not exceed 14 g/week.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Acts like a systemic oral steroid. Applying more than 50g a week will completely shut down the patient's adrenal glands, causing a fatal Addisonian crisis if stopped abruptly.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Clobetasol is the most potent (superpotent) topical corticosteroid for severe, resistant dermatoses, but must be limited to 2 weeks maximum and never used on the face due to severe atrophic side effects.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — Iatrogenic Cushing's syndrome and severe HPA axis suppression. The adrenal glands go to sleep due to massive systemic absorption.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "CRITICAL — Rapid, irreversible skin atrophy, tearing, bruising, and stretch marks if applied to normal skin.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Psoriasis / Lichen Sclerosus", + "val": "**Topical** Apply a very thin layer **OD** to **BD** ONLY to the affected thick plaques. Stop immediately when cleared.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dermol, Dermovate", + "tags": [] + }, + { + "key": "Topical Routes", + "val": "Cream/Ointment 0.05%. Scalp application.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Recalcitrant severe psoriasis, lichen planus, discoid lupus, severe vulvar lichen sclerosus.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The absolute last resort topical therapy. Used to treat conditions that mimic thick leather, where normal drugs bounce off.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Do not use on face, scalp, groin, axillae, flexural/intertriginous areas, ulcers, or under occlusive dressings. Contraindicated in children/adolescents under 18 and in untreated bacterial, fungal, viral, tubercular, or syphilitic skin disease, rosacea, acne, perioral dermatitis, and perianal/genital pruritus.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Clobetasol product guidance contraindicates use in children and adolescents under 18." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — Pregnancy Category B3; use only if benefit justifies risk. Avoid large amounts, prolonged use, and occlusion.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Clobetasol pregnancy exposure requires benefit-risk review; avoid high-dose, prolonged, or occlusive use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive immunosuppression with systemic agents.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Limit to <=2 consecutive weeks and <=14 g/week. Review diagnosis if not improved; monitor for local atrophy and systemic steroid effects with high-potency, large-area, or prolonged use.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check morning cortisol if prolonged high-dose use is suspected.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Psoriasis Rebound", + "val": "If Clobetasol is abruptly stopped after weeks of use on severe psoriasis, the patient will suffer a horrific, full-body 'pustular psoriasis' flare that can be fatal. It must be tapered down to weaker steroids (Betamethasone -> Hydrocortisone) slowly.", + "tags": [] + }, + { + "key": "Lichen Sclerosus exception", + "val": "The one exception to the 'never in the groin' rule is Lichen Sclerosus (a severe, scarring autoimmune disease of the vulva). Clobetasol is the ONLY drug strong enough to stop the scarring, and the vulvar skin is uniquely resistant to thinning from it.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Massively potent glucocorticoid. Penetrates deeply into thick, keratinized plaques to exert intense local immunosuppression and vasoconstriction.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "High risk of systemic absorption (acts systemically).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: XOBET clobetasol Australian PI/CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Topical Glucocorticoid — Ultra-potent topical corticosteroid (Class I / Super-Potent)." + }, + { + "label": "Route / Formulation", + "value": "Cream/Ointment 0.05%. Scalp application. (Dermol, Dermovate)" + }, + { + "label": "Usual Dose & Max", + "value": "**Topical** Apply sparingly **OD** to **BD** to affected areas only. Max **14 g/week** and **2 consecutive weeks**; avoid face, scalp, groin, axillae, flexures, occlusion, and children/adolescents <18." + }, + { + "label": "Best Uses", + "value": "Clobetasol is the most potent (superpotent) topical corticosteroid for severe, resistant dermatoses, but must be limited to 2 weeks maximum and never used on the face due to severe atrophic side effects." + }, + { + "label": "Avoid / Cautions", + "value": "Face, groin, axillae. Children < 12 years. Widespread use over large body surface areas. Occlusive dressings. **Pregnancy** Category C. (Avoid. High risk of systemic fetal exposure)." + }, + { + "label": "Key Risks", + "value": "Endocrine: Iatrogenic Cushing's syndrome and severe HPA axis suppression. The adrenal glands go to sleep due to massive systemic absorption. Dermatological: Rapid, irreversible skin atrophy, tearing, bruising, and stretch marks if applied to normal skin." + }, + { + "label": "Key Interactions", + "value": "Additive immunosuppression with systemic agents." + }, + { + "label": "Monitoring", + "value": "Weigh the tube. If the patient goes through more than one 50g tube in a week, they are overdosing and their adrenal glands are shut down. Check morning cortisol if prolonged high-dose use is suspected." + }, + { + "label": "Clinical Pearl", + "value": "If Clobetasol is abruptly stopped after weeks of use on severe psoriasis, the patient will suffer a horrific, full-body 'pustular psoriasis' flare that can be fatal. It must be tapered down to weaker steroids (Betamethasone -> Hydrocortisone) slowly." + } + ] + }, + { + "slug": "hydrocortisone-1", + "name": "Hydrocortisone 1%", + "class": "Steroid", + "subclass": "Topical Glucocorticoid", + "category": "Dermatology - Topical Corticosteroids", + "accent": "#475569", + "tag": "STEROID", + "schedule": "S3", + "stats": [ + { + "label": "Potency", + "value": "MILD", + "cls": "good", + "flag": "" + }, + { + "label": "Max Use", + "value": "1-2 WEEKS", + "cls": "warn", + "flag": "" + }, + { + "label": "Face Safe", + "value": "YES", + "cls": "good", + "flag": "" + }, + { + "label": "Skin Thinning", + "value": "LOW RISK", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Mild topical corticosteroid. The safest and most universally used steroid for basic eczema, dermatitis, and sensitive areas.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Apply a thin layer **BD** for 1-2 weeks.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The ONLY class of steroid that is safe to use on the face, groin, or axillae. Stronger steroids will cause irreversible skin thinning in these areas.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Hydrocortisone 1% is the mildest topical corticosteroid suitable for sensitive areas including the face and flexures, but is insufficient for thick plaques or severe dermatitis.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Dermatological", + "val": "LOW — Skin atrophy (thinning), striae (stretch marks), telangiectasia. (Risk is very low with 1% Hydrocortisone unless abused for months).", + "tags": [] + }, + { + "key": "Systemic", + "val": "SAFE — HPA axis suppression is virtually impossible unless applied to massively denuded skin under occlusion.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Eczema / Contact Dermatitis", + "val": "**Topical** Apply a thin layer to affected area 1 to 2 times daily. Rub in gently.", + "tags": [] + }, + { + "key": "Application Metric", + "val": "Use the 'Finger Tip Unit' (FTU). 1 FTU (cream from the tip of an adult index finger to the first crease) covers an area equal to two adult hands.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "DermaCort, Sigmacort, Cortic-DS", + "tags": [] + }, + { + "key": "Topical Routes", + "val": "Cream 1%, Ointment 1% (Ointment is greasy, better for dry/scaly skin. Cream is better for weeping areas).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (S2/S3).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Mild inflammatory skin conditions, facial dermatitis, nappy rash (with extreme caution).", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line baseline topical anti-inflammatory.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Do not use on untreated bacterial, fungal, or viral skin infection, chickenpox, cold sores, shingles, tuberculosis of the skin, acne, rosacea, perioral dermatitis, ulcers, or where skin is broken unless directed.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — Pregnancy Category A, but use the lowest effective amount for the shortest time and avoid prolonged/occlusive use without review.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Hydrocortisone 1% is Category A but still requires sensible lowest-effective topical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "NONE — No systemic interactions.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Stop once inflammation has cleared. Review if symptoms persist or infection is suspected; avoid prolonged continuous use, occlusive dressings, and unsupervised infant/nappy-area use.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "caution", + "severity": "caution", + "match": { + "age": { + "lt": 2 + } + }, + "note": "Existing row warns against unsupervised infant/nappy-area use; highlights for infants and toddlers because site-specific nappy-area use is not modeled." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Nappy Rash Trap", + "val": "Never use topical steroids on a baby's nappy rash unless directed by a pediatrician. The diaper acts as an 'occlusive dressing', driving the steroid deep into the skin and blood, risking systemic adrenal suppression.", + "tags": [] + }, + { + "key": "Cream vs Ointment", + "val": "Ointments trap moisture and are 20% more potent than creams of the exact same drug concentration. Use ointments for thick, dry, scaly psoriasis. Use creams for wet, oozing eczema.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to intracellular glucocorticoid receptors in the skin, suppressing pro-inflammatory cytokines, reducing local erythema, itching, and swelling.", + "tags": [] + }, + { + "key": "Onset", + "val": "Hours to days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Local action. Systemic absorption is < 1% on intact skin.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: SIGMACORT/hydrocortisone Australian PI/CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Topical Glucocorticoid — Mild topical corticosteroid." + }, + { + "label": "Route / Formulation", + "value": "Cream 1%, Ointment 1% (Ointment is greasy, better for dry/scaly skin. Cream is better for weeping areas). (DermaCort, Sigmacort, Cortic-DS)" + }, + { + "label": "Usual Dose & Max", + "value": "**Topical** Apply a thin layer to affected area 1 to 2 times daily. Rub in gently. Apply a thin layer **BD** for 1-2 weeks." + }, + { + "label": "Key Indication Doses", + "value": "Eczema / Contact Dermatitis: **Topical** Apply a thin layer to affected area 1 to 2 times daily. Rub in gently. Application Metric: Use the 'Finger Tip Unit' (FTU). 1 FTU (cream from the tip of an adult index finger to the first crease) covers an area equal to two adult hands." + }, + { + "label": "Best Uses", + "value": "Hydrocortisone 1% is the mildest topical corticosteroid suitable for sensitive areas including the face and flexures, but is insufficient for thick plaques or severe dermatitis." + }, + { + "label": "Avoid / Cautions", + "value": "Untreated bacterial, fungal (e.g., ringworm), or viral (Herpes/Shingles) skin infections. Steroids act as 'fertilizer' for infections, making them explode. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Dermatological: Skin atrophy (thinning), striae (stretch marks), telangiectasia. (Risk is very low with 1% Hydrocortisone unless abused for months). Systemic: HPA axis suppression is virtually impossible unless applied to massively denuded skin under occlusion." + }, + { + "label": "Key Interactions", + "value": "NONE — No systemic interactions." + }, + { + "label": "Monitoring", + "value": "Ensure the patient stops using it once the inflammation has cleared to prevent rebound flares or skin atrophy." + }, + { + "label": "Clinical Pearl", + "value": "Never use topical steroids on a baby's nappy rash unless directed by a pediatrician. The diaper acts as an 'occlusive dressing', driving the steroid deep into the skin and blood, risking systemic adrenal suppression." + } + ] + }, + { + "slug": "triamcinolone", + "name": "Triamcinolone", + "class": "Steroid", + "subclass": "Topical Glucocorticoid", + "category": "Dermatology - Topical Corticosteroids", + "accent": "#475569", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Potency", + "value": "MODERATE", + "cls": "warn", + "flag": "" + }, + { + "label": "Max Use", + "value": "2-4 WEEKS", + "cls": "warn", + "flag": "" + }, + { + "label": "Face Safe", + "value": "AVOID", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Dental Paste", + "value": "AVAILABLE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Moderate-potency topical corticosteroid. The workhorse for stubborn eczema and psoriasis on the body and limbs.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Apply a thin layer **BD** to **TDS**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Too strong for the face or groin. Will cause permanent thinning, visible blood vessels (telangiectasia), and steroid-induced rosacea.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Triamcinolone is a moderate-potency topical corticosteroid for inflammatory dermatoses and intra-articular injection, but can cause skin atrophy with prolonged use and adrenal suppression if used extensively.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Dermatological", + "val": "MODERATE — Skin atrophy, striae, hypopigmentation, hypertrichosis (excess hair growth), perioral dermatitis if used near the mouth.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Eczema / Psoriasis", + "val": "**Topical** Apply 1-3 times daily to body/limbs.", + "tags": [] + }, + { + "key": "Severe Mouth Ulcers (Aphthous)", + "val": "**Topical** Apply dental paste (Kenalog in Orabase) to the ulcer **BD** after meals. Do not rub in; dab it on to form a protective seal.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Aristocort, Kenalog in Orabase", + "tags": [] + }, + { + "key": "Topical Routes", + "val": "Cream/Ointment 0.02% (Aristocort). Dental paste 0.1% (Kenalog).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4). Kenalog dental paste is OTC (S3).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Corticosteroid-responsive dermatoses, severe aphthous ulcers.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Step-up therapy when 1% Hydrocortisone fails on the torso or limbs.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Untreated bacterial, fungal, or viral skin infection, chickenpox, cold sores, shingles, tuberculosis of the skin, acne, rosacea, perioral dermatitis, ulcers, or broken/infected skin. Avoid face, groin, and axillae unless specifically directed.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — Pregnancy Category A for topical triamcinolone; use the lowest effective potency and amount for the shortest time.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Topical triamcinolone is Category A but should still use the lowest effective amount and duration." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "NONE.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Step down or cease once controlled. Review if infection is suspected, symptoms persist, or prolonged/large-area use is needed; avoid continuous unsupervised use.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Orabase Secret", + "val": "Kenalog in Orabase is a gritty paste. If the patient tries to rub it into the mouth ulcer, it clumps and falls off. They MUST take a tiny dab on a cotton swab and press it gently onto the ulcer once, letting the saliva turn it into an adhesive plaster.", + "tags": [] + }, + { + "key": "The Fluorine Factor", + "val": "Adding a fluorine atom to a steroid (like Triamcinolone) massively spikes its potency and skin-penetration. Fluorinated steroids should never touch the face.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Fluorinated glucocorticoid. Significantly more lipophilic and receptor-affine than hydrocortisone, penetrating the stratum corneum effectively.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Local action. Minimal systemic absorption.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: ARISTOCORT/KENALOG triamcinolone Australian PI/CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Topical Glucocorticoid — Moderate-potency topical corticosteroid." + }, + { + "label": "Route / Formulation", + "value": "Cream/Ointment 0.02% (Aristocort). Dental paste 0.1% (Kenalog). (Aristocort, Kenalog in Orabase)" + }, + { + "label": "Usual Dose & Max", + "value": "**Topical** Apply 1-3 times daily to body/limbs. Apply a thin layer **BD** to **TDS**." + }, + { + "label": "Key Indication Doses", + "value": "Severe Eczema / Psoriasis: **Topical** Apply 1-3 times daily to body/limbs. Severe Mouth Ulcers (Aphthous): **Topical** Apply dental paste (Kenalog in Orabase) to the ulcer **BD** after meals. Do not rub in; dab it on to form a protective seal." + }, + { + "label": "Best Uses", + "value": "Triamcinolone is a moderate-potency topical corticosteroid for inflammatory dermatoses and intra-articular injection, but can cause skin atrophy with prolonged use and adrenal suppression if used extensively." + }, + { + "label": "Avoid / Cautions", + "value": "Untreated skin infections, acne vulgaris, rosacea. Application to face/groin/axillae. **Pregnancy** Category A (Safe, but use the lowest potency needed)." + }, + { + "label": "Key Risks", + "value": "Dermatological: Skin atrophy, striae, hypopigmentation, hypertrichosis (excess hair growth), perioral dermatitis if used near the mouth." + }, + { + "label": "Key Interactions", + "value": "NONE." + }, + { + "label": "Monitoring", + "value": "Step down to hydrocortisone or cease once the flare is controlled. Do not use continuously for months." + }, + { + "label": "Clinical Pearl", + "value": "Kenalog in Orabase is a gritty paste. If the patient tries to rub it into the mouth ulcer, it clumps and falls off. They MUST take a tiny dab on a cotton swab and press it gently onto the ulcer once, letting the saliva turn it into an adhesive plaster." + } + ] + }, + { + "slug": "dulaglutide", + "name": "Dulaglutide", + "class": "Antidiabetic", + "subclass": "GLP-1 Agonist", + "category": "Endocrinology - Insulins & Injectables", + "accent": "#16a34a", + "tag": "GLP-1", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1.5 mg/week", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5 Days", + "cls": "", + "flag": "" + }, + { + "label": "Device", + "value": "AUTO-INJECTOR", + "cls": "good", + "flag": "" + }, + { + "label": "Pancreatitis", + "value": "RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Once-weekly GLP-1 receptor agonist. Highly prized for its incredibly simple, hidden-needle auto-injector device. Excellent cardiovascular benefits.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1.5 mg/week**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Provides identical benefits to Ozempic, but often preferred by patients with severe needle phobia.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dulaglutide is a once-weekly GLP-1 agonist for type 2 diabetes with cardiovascular benefit, but causes GI side effects and is contraindicated in personal/family history of medullary thyroid carcinoma.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, vomiting, diarrhea, dyspepsia. CRITICAL — Acute pancreatitis.", + "tags": [] + }, + { + "key": "Endocrine", + "val": "MODERATE — Theoretical risk of Medullary Thyroid Carcinoma.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Mild increase in resting heart rate.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes", + "val": "**SC** 1.5 mg ONCE WEEKLY. (Can be taken at any time of day, with or without meals).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CAUTION — No dose adjustment required in mild/moderate CKD. Avoid in end-stage renal disease (eGFR < 15).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Trulicity", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Single-use, pre-filled auto-injector pens (1.5 mg/0.5 mL). The needle is hidden and automatically retracts.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 2 Diabetes, reduction of major cardiovascular events.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Direct competitor to Semaglutide. Highly effective for T2DM with established cardiovascular disease.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Personal/family history of Medullary Thyroid Carcinoma or MEN 2. History of pancreatitis.", + "tags": [] + }, + { + "key": "Surgery", + "val": "MANDATORY — Withhold prior to general anaesthesia due to delayed gastric emptying/aspiration risk.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "MODERATE — Delayed gastric emptying can slightly delay the absorption of concomitant oral medications.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Counsel the patient to place the pen flat against the skin, unlock it, and press the button. They will hear a click, wait 5-10 seconds, hear a second click, and it is done. They never see the needle.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **HbA1c**, **U&E**, and **Weight**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Compliance King", + "val": "Because the needle is 100% invisible and the dose is pre-measured (no dial to turn like Ozempic), Dulaglutide has the highest patient compliance rate among the injectable diabetes drugs, particularly in the elderly or needle-phobic.", + "tags": [] + }, + { + "key": "The 'Full' Feeling", + "val": "Educate the patient to stop eating the moment they feel full. Pushing past the 'full' signal while on a GLP-1 will guarantee severe vomiting.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "GLP-1 analogue fused to an IgG4 Fc fragment. This massive molecular size prevents it from being filtered by the kidneys and shields it from DPP-4 degradation.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5 Days (Allows once-weekly dosing).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TRULICITY ARTG/PI, PBS search, and TGA GLP-1 aspiration warning checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "GLP-1 Agonist — Once-weekly GLP-1 receptor agonist." + }, + { + "label": "Route / Formulation", + "value": "Single-use, pre-filled auto-injector pens (1.5 mg/0.5 mL). The needle is hidden and automatically retracts. (Trulicity)" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** 1.5 mg ONCE WEEKLY. (Can be taken at any time of day, with or without meals). Max **1.5 mg/week**." + }, + { + "label": "Key Indication Doses", + "value": "Type 2 Diabetes: **SC** 1.5 mg ONCE WEEKLY. (Can be taken at any time of day, with or without meals). Renal Impairment: No dose adjustment required in mild/moderate CKD. Avoid in end-stage renal disease (eGFR < 15)." + }, + { + "label": "Best Uses", + "value": "Dulaglutide is a once-weekly GLP-1 agonist for type 2 diabetes with cardiovascular benefit, but causes GI side effects and is contraindicated in personal/family history of medullary thyroid carcinoma." + }, + { + "label": "Avoid / Cautions", + "value": "Personal/family history of Medullary Thyroid Carcinoma or MEN 2. History of pancreatitis. **Pregnancy** Category D." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea, vomiting, diarrhea, dyspepsia. CRITICAL — Acute pancreatitis. Endocrine: Theoretical risk of Medullary Thyroid Carcinoma. Cardiovascular: Mild increase in resting heart rate." + }, + { + "label": "Key Interactions", + "value": "Delayed gastric emptying can slightly delay the absorption of concomitant oral medications." + }, + { + "label": "Monitoring", + "value": "Counsel the patient to place the pen flat against the skin, unlock it, and press the button. They will hear a click, wait 5-10 seconds, hear a second click, and it is done. They never see the needle. Routine **HbA1c**, **U&E**, and **Weight**." + }, + { + "label": "Clinical Pearl", + "value": "Because the needle is 100% invisible and the dose is pre-measured (no dial to turn like Ozempic), Dulaglutide has the highest patient compliance rate among the injectable diabetes drugs, particularly in the elderly or needle-phobic." + } + ] + }, + { + "slug": "exenatide", + "name": "Exenatide", + "class": "Antidiabetic", + "subclass": "GLP-1 Agonist", + "category": "Endocrinology - Insulins & Injectables", + "accent": "#16a34a", + "tag": "GLP-1", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "2 mg/week (XR)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2.4 h (IR)", + "cls": "", + "flag": "" + }, + { + "label": "Weight Loss", + "value": "POTENT", + "cls": "good", + "flag": "" + }, + { + "label": "Pancreatitis", + "value": "RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The original GLP-1 receptor agonist (derived from Gila monster saliva). Suppresses appetite, slows gastric emptying, and forces glucose-dependent insulin release.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mcg/day** (Byetta BD) OR **2 mg/week** (Bydureon XR).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly dependent on renal clearance. Strictly contraindicated in severe renal failure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Exenatide is a GLP-1 receptor agonist for type 2 diabetes with weight loss benefits, but requires injection and causes significant nausea initially.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea (very common, affects > 40%), vomiting, diarrhea. CRITICAL — Acute pancreatitis.", + "tags": [] + }, + { + "key": "Renal", + "val": "HIGH — Acute kidney injury (mostly secondary to severe dehydration from vomiting/nausea).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "SAFE — Zero inherent hypoglycemia risk (unless combined with insulin/sulfonylureas). Excellent weight loss.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes (Immediate Release)", + "val": "**SC** 5 mcg **BD** (within 60 mins BEFORE morning and evening meals). Titrate to 10 mcg BD after 1 month.", + "tags": [] + }, + { + "key": "Type 2 Diabetes (Extended Release)", + "val": "**SC** 2 mg ONCE WEEKLY (Bydureon).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Avoid entirely if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Byetta (BD), Bydureon (Weekly)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled pens for **SC** injection.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 2 Diabetes Mellitus.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Largely superseded by Semaglutide and Dulaglutide due to their superior cardiovascular benefits and easier administration, but still used.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal impairment (**eGFR** < 30), history of pancreatitis, severe gastroparesis.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Exenatide is contraindicated/avoided in severe renal impairment." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Because it paralyzes the stomach (slows gastric emptying), it can severely delay the absorption of oral drugs that require rapid peak levels (e.g., Paracetamol, oral contraceptives, antibiotics).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn patient to report severe, radiating upper abdominal pain with vomiting immediately (Pancreatitis).", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **HbA1c**, **U&E**, and **Weight**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Nausea Curve", + "val": "Nausea is the primary reason patients quit. Reassure them that the nausea is mostly mediated by the brain (CTZ) adjusting to the hormone and usually fades significantly after 4-8 weeks.", + "tags": [] + }, + { + "key": "The Byetta Timing", + "val": "Byetta (IR) MUST be given within the 60 minutes *before* a meal. If given after eating, the patient will experience severe gastrointestinal distress and no glucose benefit.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Mimics endogenous Incretin (GLP-1). Stimulates insulin release (only when glucose is high), suppresses post-prandial glucagon, heavily slows gastric emptying (causing early satiety), and reduces appetite centrally.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2.4 hours (Byetta). Excreted primarily by glomerular filtration.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - BYETTA/BYDUREON AusPAR PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "GLP-1 Agonist — The original GLP-1 receptor agonist (derived from Gila monster saliva)." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled pens for **SC** injection. (Byetta (BD), Bydureon (Weekly))" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** 5 mcg **BD** (within 60 mins BEFORE morning and evening meals). Titrate to 10 mcg BD after 1 month. Max **20 mcg/day** (Byetta BD) OR **2 mg/week** (Bydureon XR)." + }, + { + "label": "Key Indication Doses", + "value": "Type 2 Diabetes (Immediate Release): **SC** 5 mcg **BD** (within 60 mins BEFORE morning and evening meals). Titrate to 10 mcg BD after 1 month. Type 2 Diabetes (Extended Release): **SC** 2 mg ONCE WEEKLY (Bydureon). Renal Impairment: Avoid entirely if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Exenatide is a GLP-1 receptor agonist for type 2 diabetes with weight loss benefits, but requires injection and causes significant nausea initially." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal impairment (**eGFR** < 30), history of pancreatitis, severe gastroparesis. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea (very common, affects > 40%), vomiting, diarrhea. CRITICAL — Acute pancreatitis. Renal: Acute kidney injury (mostly secondary to severe dehydration from vomiting/nausea). Metabolic: Zero inherent hypoglycemia risk (unless combined with insulin/sulfonylureas). Excellent weight loss." + }, + { + "label": "Key Interactions", + "value": "Because it paralyzes the stomach (slows gastric emptying), it can severely delay the absorption of oral drugs that require rapid peak levels (e.g., Paracetamol, oral contraceptives, antibiotics)." + }, + { + "label": "Monitoring", + "value": "Warn patient to report severe, radiating upper abdominal pain with vomiting immediately (Pancreatitis). Routine **HbA1c**, **U&E**, and **Weight**." + }, + { + "label": "Clinical Pearl", + "value": "Nausea is the primary reason patients quit. Reassure them that the nausea is mostly mediated by the brain (CTZ) adjusting to the hormone and usually fades significantly after 4-8 weeks." + } + ] + }, + { + "slug": "humalog-mix-25-50", + "name": "Humalog Mix 25/50", + "class": "Antidiabetic", + "subclass": "Biphasic Insulin", + "category": "Endocrinology - Insulins & Injectables", + "accent": "#16a34a", + "tag": "INSULIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Composition", + "value": "Varies", + "cls": "warn", + "flag": "" + }, + { + "label": "Timing", + "value": "STRICTLY BD", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Cloudy", + "value": "MUST MIX", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Pre-mixed biphasic insulin. Uses Insulin Lispro as the rapid component, and Protamine Lispro as the slow component. Comes in different ratios depending on the patient's carb intake.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated based on BSL.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Mix 25 contains 25% fast insulin. Mix 50 contains 50% fast insulin. Mixing them up causes catastrophic hypos or massive hyperglycemia.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Humalog Mix 25/50 is a biphasic insulin mix for patients needing simplified injection regimens, but limits dose flexibility compared to basal-bolus therapy and increases hypoglycaemia risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Hypoglycemia. HIGH — Weight gain.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes", + "val": "**SC** Administered **BD** (before Breakfast and Dinner).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Humalog Mix 25, Humalog Mix 50", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled pens (100 U/mL). Cloudy white suspension. MUST BE ROLLED.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 1 and Type 2 Diabetes.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Alternative to NovoMix 30. Mix 50 is specifically used for patients who eat massive, high-carb meals and need a stronger immediate insulin hit.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active hypoglycemia. IV administration.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Humalog Mix pregnancy row is Category A/safe and should not trigger a contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers, steroids.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Must be thoroughly re-suspended (rolled) before every single injection to ensure the fast/slow ratio is accurate.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Double check the box. Is it Mix 25 or Mix 50?", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Carb Ratio", + "val": "A patient who eats a light piece of toast for breakfast needs Mix 25. A patient who eats 4 bowls of sugary cereal needs Mix 50. The ratio is tailored to their lifestyle.", + "tags": [] + }, + { + "key": "Not for DKA", + "val": "Never use cloudy, pre-mixed insulins to treat DKA or for sliding-scale corrections. The protracted release will cause uncontrollable hypoglycemia 12 hours later.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Combines rapid-acting Lispro with intermediate-acting Protamine-bound Lispro.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 10-15 mins.", + "tags": [] + }, + { + "key": "Peak", + "val": "Dual peaks depending on the mix ratio.", + "tags": [] + }, + { + "key": "Duration", + "val": "14-24 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - HUMALOG MIX25 ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Biphasic Insulin — Pre-mixed biphasic insulin." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled pens (100 U/mL). Cloudy white suspension. MUST BE ROLLED. (Humalog Mix 25, Humalog Mix 50)" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** Administered **BD** (before Breakfast and Dinner). Titrated based on BSL." + }, + { + "label": "Best Uses", + "value": "Humalog Mix 25/50 is a biphasic insulin mix for patients needing simplified injection regimens, but limits dose flexibility compared to basal-bolus therapy and increases hypoglycaemia risk." + }, + { + "label": "Avoid / Cautions", + "value": "Active hypoglycemia. IV administration. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Metabolic: Hypoglycemia. HIGH — Weight gain." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers, steroids." + }, + { + "label": "Monitoring", + "value": "Must be thoroughly re-suspended (rolled) before every single injection to ensure the fast/slow ratio is accurate. Double check the box. Is it Mix 25 or Mix 50?" + }, + { + "label": "Clinical Pearl", + "value": "A patient who eats a light piece of toast for breakfast needs Mix 25. A patient who eats 4 bowls of sugary cereal needs Mix 50. The ratio is tailored to their lifestyle." + } + ] + }, + { + "slug": "insulin-aspart", + "name": "Insulin aspart", + "class": "Antidiabetic", + "subclass": "Prandial Insulin", + "category": "Endocrinology - Insulins & Injectables", + "accent": "#16a34a", + "tag": "INSULIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "10-20 mins", + "cls": "", + "flag": "" + }, + { + "label": "Hypoglycemia", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Timing", + "value": "WITH MEALS", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-rapid-acting mealtime (prandial) insulin. Designed to perfectly mimic the physiological burst of insulin a healthy pancreas releases when food hits the stomach.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated dynamically based on meal carbohydrate content or sliding scales.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be given immediately before eating. If the patient is injected and then the meal is delayed, they will suffer a severe hypoglycemic crash.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Insulin aspart is a rapid-acting mealtime insulin for prandial glucose control and insulin pump therapy, but requires carbohydrate counting skill and carries significant hypoglycaemia risk if mistimed.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Rapid, severe hypoglycemia if meals are skipped, delayed, or lack carbohydrates. HIGH — Weight gain.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Lipohypertrophy at injection sites.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 1 / Type 2 Diabetes", + "val": "**SC** Administered 5-10 minutes prior to a meal. Dose varies (e.g., 5-15 units per meal).", + "tags": [] + }, + { + "key": "Hyperkalemia / DKA", + "val": "**IV** Regular insulin (Actrapid) is preferred for IV infusions in ICU/ED, but rapid analogues can be used SC for correction doses.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "NovoRapid, Fiasp (ultra-fast)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled pens or cartridges for **SC** injection (100 U/mL). Clear solution.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Glycemic control at mealtimes in Type 1 and Type 2 DM. Correction of acute hyperglycemia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The 'Bolus' in the basal-bolus regimen.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — During active hypoglycemia. Patient refusing to eat.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. Widely used in gestational diabetes.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Insulin aspart pregnancy row is Category A/safe and should not trigger a contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers (masks hypo symptoms). Alcohol (blocks hepatic gluconeogenesis, exacerbating hypos).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — **BSL** checks pre-meals. Ensure the food tray is physically on the table before the nurse administers the injection.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **HbA1c**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Fiasp Difference", + "val": "Fiasp is Insulin Aspart with added Niacinamide, which acts as a vasodilator. It absorbs even faster than NovoRapid. It can literally be injected *as* the patient takes their first bite of food.", + "tags": [] + }, + { + "key": "The Correction Factor", + "val": "1 unit of rapid-acting insulin typically drops the blood sugar by ~2 to 3 mmol/L in an average adult. Do not 'stack' correction doses; wait 3 hours for the first dose to finish acting before correcting again.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "A single amino acid substitution (proline replaced by aspartic acid) prevents the insulin molecules from clumping together as hexamers. They remain as single monomers, allowing them to instantly diffuse into the bloodstream.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 10-20 mins.", + "tags": [] + }, + { + "key": "Peak", + "val": "1-3 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "3-5 hours (Matches the digestion time of a standard meal).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - NOVORAPID ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Prandial Insulin — Ultra-rapid-acting mealtime (prandial) insulin." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled pens or cartridges for **SC** injection (100 U/mL). Clear solution. (NovoRapid, Fiasp (ultra-fast))" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** Administered 5-10 minutes prior to a meal. Dose varies (e.g., 5-15 units per meal). Titrated dynamically based on meal carbohydrate content or sliding scales." + }, + { + "label": "Key Indication Doses", + "value": "Type 1 / Type 2 Diabetes: **SC** Administered 5-10 minutes prior to a meal. Dose varies (e.g., 5-15 units per meal). Hyperkalemia / DKA: **IV** Regular insulin (Actrapid) is preferred for IV infusions in ICU/ED, but rapid analogues can be used SC for correction doses." + }, + { + "label": "Best Uses", + "value": "Insulin aspart is a rapid-acting mealtime insulin for prandial glucose control and insulin pump therapy, but requires carbohydrate counting skill and carries significant hypoglycaemia risk if mistimed." + }, + { + "label": "Avoid / Cautions", + "value": "During active hypoglycemia. Patient refusing to eat. **Pregnancy** Category A. Widely used in gestational diabetes." + }, + { + "label": "Key Risks", + "value": "Metabolic: Rapid, severe hypoglycemia if meals are skipped, delayed, or lack carbohydrates. HIGH — Weight gain. Dermatological: Lipohypertrophy at injection sites." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers (masks hypo symptoms). Alcohol (blocks hepatic gluconeogenesis, exacerbating hypos)." + }, + { + "label": "Monitoring", + "value": "**BSL** checks pre-meals. Ensure the food tray is physically on the table before the nurse administers the injection. Routine **HbA1c**." + }, + { + "label": "Clinical Pearl", + "value": "Fiasp is Insulin Aspart with added Niacinamide, which acts as a vasodilator. It absorbs even faster than NovoRapid. It can literally be injected *as* the patient takes their first bite of food." + } + ] + }, + { + "slug": "insulin-degludec", + "name": "Insulin degludec", + "class": "Antidiabetic", + "subclass": "Ultra-Long Basal Insulin", + "category": "Endocrinology - Insulins & Injectables", + "accent": "#16a34a", + "tag": "INSULIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Duration", + "value": "42 HOURS", + "cls": "good", + "flag": "good" + }, + { + "label": "Timing", + "value": "FLEXIBLE", + "cls": "good", + "flag": "" + }, + { + "label": "Hypos", + "value": "LOWER RISK", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-long-acting basal insulin. Forms multi-hexamer chains under the skin, taking days to absorb. Provides the flattest, most consistent 24-hour profile with the lowest risk of nocturnal hypos.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated to fasting BSL.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Because it lasts 42 hours, the injection timing is incredibly flexible. A patient can take it at 8 AM one day and 8 PM the next day without risking gaps or overlap.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Insulin degludec is an ultra-long-acting basal insulin with the lowest hypoglycaemia risk and flexible dosing, but is more expensive and offers marginal benefit over glargine for most patients.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Hypoglycemia. However, Degludec has a statistically significantly lower risk of severe nocturnal hypoglycemia compared to Glargine.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Lipohypertrophy.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 1 / Type 2 Diabetes", + "val": "**SC** Administered ONCE daily at any time of day. Ensure at least 8 hours between doses.", + "tags": [] + }, + { + "key": "Dose Adjustments", + "val": "MANDATORY — Because it takes 3-4 days to reach steady state, do NOT adjust the dose more frequently than every 3-4 days, or you will cause a stacking overdose.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Tresiba", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled pens for **SC** injection (100 U/mL). Clear solution.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 1 and Type 2 Diabetes.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The most advanced basal insulin. The absolute best choice for shift workers or teenagers with chaotic schedules who cannot take their insulin at the exact same time every day.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active hypoglycemia.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Insulin degludec pregnancy row is Category B3/caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Corticosteroids (spike BSL), Beta-blockers (mask hypos).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor fasting **BSL**.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **HbA1c**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Shift Worker's Insulin", + "val": "With Glargine, a 4-hour delay in injection causes a massive BSL spike, and taking it 4 hours early causes a severe overlap hypo. With Degludec, the 42-hour duration means the patient has a massive buffer. They can inject it whenever it is convenient that day.", + "tags": [] + }, + { + "key": "The DKA Buffer", + "val": "If a Type 1 diabetic forgets their basal insulin completely for a day, Glargine washes out and they go into DKA. Degludec's massive tail provides an extra 24 hours of background coverage, heavily protecting against missed-dose DKA.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Upon injection, it forms massive, stable multi-hexamer structures in the subcutaneous tissue. Zinc slowly diffuses away, allowing single insulin monomers to break off at a glacial, completely steady rate into the blood.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "42 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "25 hours (Steady state takes 3-4 days).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TRESIBA ARTG/AusPAR PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Ultra-Long Basal Insulin — Ultra-long-acting basal insulin." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled pens for **SC** injection (100 U/mL). Clear solution. (Tresiba)" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** Administered ONCE daily at any time of day. Ensure at least 8 hours between doses. Titrated to fasting BSL." + }, + { + "label": "Key Indication Doses", + "value": "Type 1 / Type 2 Diabetes: **SC** Administered ONCE daily at any time of day. Ensure at least 8 hours between doses. Dose Adjustments: Because it takes 3-4 days to reach steady state, do NOT adjust the dose more frequently than every 3-4 days, or you will cause a stacking overdose." + }, + { + "label": "Best Uses", + "value": "Insulin degludec is an ultra-long-acting basal insulin with the lowest hypoglycaemia risk and flexible dosing, but is more expensive and offers marginal benefit over glargine for most patients." + }, + { + "label": "Avoid / Cautions", + "value": "Active hypoglycemia. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Metabolic: Hypoglycemia. However, Degludec has a statistically significantly lower risk of severe nocturnal hypoglycemia compared to Glargine. Dermatological: Lipohypertrophy." + }, + { + "label": "Key Interactions", + "value": "Corticosteroids (spike BSL), Beta-blockers (mask hypos)." + }, + { + "label": "Monitoring", + "value": "Monitor fasting **BSL**. Routine **HbA1c**." + }, + { + "label": "Clinical Pearl", + "value": "With Glargine, a 4-hour delay in injection causes a massive BSL spike, and taking it 4 hours early causes a severe overlap hypo. With Degludec, the 42-hour duration means the patient has a massive buffer. They can inject it whenever it is convenient that day." + } + ] + }, + { + "slug": "insulin-detemir", + "name": "Insulin detemir", + "class": "Antidiabetic", + "subclass": "Basal Insulin", + "category": "Endocrinology - Insulins & Injectables", + "accent": "#16a34a", + "tag": "INSULIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Duration", + "value": "16-24 h", + "cls": "warn", + "flag": "" + }, + { + "label": "Freq", + "value": "OFTEN BD", + "cls": "warn", + "flag": "" + }, + { + "label": "Weight Gain", + "value": "LOWER RISK", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Long-acting basal insulin. Binds to albumin in the blood to delay its action. Often lasts less than 24 hours, frequently requiring twice-daily dosing to prevent gap hyperglycemia.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated strictly to fasting BSL.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Uniquely associated with slightly LESS weight gain than Glargine or old NPH insulins.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Insulin detemir is a long-acting basal insulin with less weight gain than glargine, but may require twice-daily dosing and has largely been superseded by insulin degludec.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Hypoglycemia. HIGH — Hypokalemia (insulin drives K+ into cells).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Lipohypertrophy (lumps) at injection sites.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 1 / Type 2 Diabetes", + "val": "**SC** Administered once or twice daily. If given OD, usually given at dinner or bedtime. If coverage fails at 18 hours, must be split into **BD** dosing.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce dose in severe renal failure to prevent severe hypos.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Levemir", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled pens or cartridges for **SC** injection (100 U/mL). Clear solution.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 1 and Type 2 Diabetes.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "A solid basal insulin, but increasingly superseded by Glargine or Degludec due to its annoying tendency to require BD injections in many patients.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active hypoglycemia.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. Highly studied and very safe for basal coverage in gestational/Type 1 pregnancy.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Insulin detemir pregnancy row is Category A/safe and should not trigger a contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers mask hypoglycemia. Corticosteroids massively increase insulin requirements.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Check fasting **BSL**. If fasting BSL is good, but pre-dinner BSL is 18, the Detemir is wearing off at 16 hours. Split the dose to BD.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **HbA1c**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Weight Advantage", + "val": "For reasons not entirely understood (potentially related to BBB penetration and satiety signals), Detemir causes statistically less weight gain than Glargine. A good choice for obese T2DM patients requiring basal insulin.", + "tags": [] + }, + { + "key": "Never IV", + "val": "Detemir must NEVER be given IV. The massive albumin binding would cause entirely unpredictable and dangerous kinetics.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "A fatty acid (myristic acid) is chemically bound to the insulin molecule. Once injected, it binds tightly to albumin in the subcutaneous tissue and in the blood, creating a slow, steady release of free insulin.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "16-24 hours (Dose-dependent. Low doses wear off very fast).", + "tags": [] + }, + { + "key": "Peak", + "val": "Relatively flat, but has a slight peak at 6-8 hours compared to Glargine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - LEVEMIR ARTG, AusPAR PI, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Basal Insulin — Long-acting basal insulin." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled pens or cartridges for **SC** injection (100 U/mL). Clear solution. (Levemir)" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** Administered once or twice daily. If given OD, usually given at dinner or bedtime. If coverage fails at 18 hours, must be split into **BD** dosing. Titrated strictly to fasting BSL." + }, + { + "label": "Key Indication Doses", + "value": "Type 1 / Type 2 Diabetes: **SC** Administered once or twice daily. If given OD, usually given at dinner or bedtime. If coverage fails at 18 hours, must be split into **BD** dosing. Renal Impairment: Reduce dose in severe renal failure to prevent severe hypos." + }, + { + "label": "Best Uses", + "value": "Insulin detemir is a long-acting basal insulin with less weight gain than glargine, but may require twice-daily dosing and has largely been superseded by insulin degludec." + }, + { + "label": "Avoid / Cautions", + "value": "Active hypoglycemia. **Pregnancy** Category A. Highly studied and very safe for basal coverage in gestational/Type 1 pregnancy." + }, + { + "label": "Key Risks", + "value": "Metabolic: Hypoglycemia. HIGH — Hypokalemia (insulin drives K+ into cells). Dermatological: Lipohypertrophy (lumps) at injection sites." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers mask hypoglycemia. Corticosteroids massively increase insulin requirements." + }, + { + "label": "Monitoring", + "value": "Check fasting **BSL**. If fasting BSL is good, but pre-dinner BSL is 18, the Detemir is wearing off at 16 hours. Split the dose to BD. Routine **HbA1c**." + }, + { + "label": "Clinical Pearl", + "value": "For reasons not entirely understood (potentially related to BBB penetration and satiety signals), Detemir causes statistically less weight gain than Glargine. A good choice for obese T2DM patients requiring basal insulin." + } + ] + }, + { + "slug": "insulin-glargine", + "name": "Insulin glargine", + "class": "Antidiabetic", + "subclass": "Basal Insulin", + "category": "Endocrinology - Insulins & Injectables", + "accent": "#16a34a", + "tag": "INSULIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Duration", + "value": "24 h", + "cls": "good", + "flag": "" + }, + { + "label": "Hypoglycemia", + "value": "RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Peak", + "value": "PEAKLESS", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-long-acting, 'peakless' basal insulin. Provides a flat, continuous background level of insulin to suppress hepatic glucose production overnight and between meals.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "No absolute max. Titrated strictly to fasting blood glucose targets.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never mix glargine in the same syringe with any other insulin, as its acidic pH will cause it to precipitate and destroy the kinetics.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Insulin glargine is the most widely used long-acting basal insulin providing 24-hour coverage, but causes weight gain and requires careful dose titration to avoid nocturnal hypoglycaemia.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Severe hypoglycemia (though lower risk than NPH due to lack of a peak). HIGH — Weight gain.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Lipohypertrophy (fatty lumps) or lipoatrophy if injection sites are not rotated.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 1 / Type 2 Diabetes", + "val": "**SC** Administered once daily, exactly at the same time each day (often NOCTE or morning). Start 10 units, titrate by 2 units every 3 days based on fasting BSL.", + "tags": [] + }, + { + "key": "Renal / Hepatic", + "val": "MANDATORY — Insulin requirements drop significantly in severe renal/hepatic failure. Reduce dose to prevent hypos.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lantus (100 U/mL), Toujeo (300 U/mL), Optisulin", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled pens or cartridges for **SC** injection. Clear, colorless solution.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 1 DM (as the basal component of a basal-bolus regimen), Type 2 DM.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The gold standard basal insulin. Provides much smoother, safer 24-hour coverage than old NPH (Protaphane) insulin.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — During an active episode of hypoglycemia.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B3 (Safe, but detemir/NPH historically have more data).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Insulin glargine pregnancy row is framed as safe/accepted in context and should not trigger a contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers mask the adrenergic warning signs of hypoglycemia (tremor/tachycardia).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Corticosteroids (Prednisolone) massively increase insulin resistance, requiring Glargine doses to be increased by 20-50%.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Check fasting morning **BSL**. This reading guides the titration of Glargine. Inspect abdomen for lipohypertrophy.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **HbA1c**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Fasting Focus", + "val": "Glargine does NOT cover the glucose spike from a meal. It only covers the background glucose the liver makes. If the patient's fasting morning sugar is perfect, but their after-dinner sugar is 18, DO NOT increase the Glargine. You will cause a 3 AM hypo. Add a prandial insulin instead.", + "tags": [] + }, + { + "key": "Toujeo Trap", + "val": "Toujeo is 300 Units/mL. Lantus is 100 Units/mL. 1 unit on the Toujeo pen clicker equals 1 unit on the Lantus pen, but the volume is tiny. Do not use standard insulin syringes to draw out of a Toujeo pen, or you will give a 3x massive overdose.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Activates insulin receptors, driving glucose into muscle/fat and inhibiting hepatic gluconeogenesis. Formulated at an acidic pH (pH 4); upon injection into neutral subcutaneous tissue (pH 7.4), it forms micro-precipitates that slowly dissolve over 24 hours.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h (Up to 36 h for the high-strength Toujeo 300U/mL).", + "tags": [] + }, + { + "key": "Peak", + "val": "Essentially peakless.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - LANTUS/TOUJEO/BASAGLAR TGA evidence and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Basal Insulin — Ultra-long-acting, 'peakless' basal insulin." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled pens or cartridges for **SC** injection. Clear, colorless solution. (Lantus (100 U/mL), Toujeo (300 U/mL), Optisulin)" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** Administered once daily, exactly at the same time each day (often NOCTE or morning). Start 10 units, titrate by 2 units every 3 days based on fasting BSL. No absolute max. Titrated strictly to fasting blood glucose targets." + }, + { + "label": "Key Indication Doses", + "value": "Type 1 / Type 2 Diabetes: **SC** Administered once daily, exactly at the same time each day (often NOCTE or morning). Start 10 units, titrate by 2 units every 3 days based on fasting BSL. Renal / Hepatic: Insulin requirements drop significantly in severe renal/hepatic failure. Reduce dose to prevent hypos." + }, + { + "label": "Best Uses", + "value": "Insulin glargine is the most widely used long-acting basal insulin providing 24-hour coverage, but causes weight gain and requires careful dose titration to avoid nocturnal hypoglycaemia." + }, + { + "label": "Avoid / Cautions", + "value": "During an active episode of hypoglycemia. **Pregnancy** Category B3 (Safe, but detemir/NPH historically have more data)." + }, + { + "label": "Key Risks", + "value": "Metabolic: Severe hypoglycemia (though lower risk than NPH due to lack of a peak). HIGH — Weight gain. Dermatological: Lipohypertrophy (fatty lumps) or lipoatrophy if injection sites are not rotated." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers mask the adrenergic warning signs of hypoglycemia (tremor/tachycardia). Corticosteroids (Prednisolone) massively increase insulin resistance, requiring Glargine doses to be increased by 20-50%." + }, + { + "label": "Monitoring", + "value": "Check fasting morning **BSL**. This reading guides the titration of Glargine. Inspect abdomen for lipohypertrophy. Routine **HbA1c**." + }, + { + "label": "Clinical Pearl", + "value": "Glargine does NOT cover the glucose spike from a meal. It only covers the background glucose the liver makes. If the patient's fasting morning sugar is perfect, but their after-dinner sugar is 18, DO NOT increase the Glargine. You will cause a 3 AM hypo. Add a prandial insulin instead." + } + ] + }, + { + "slug": "insulin-glulisine", + "name": "Insulin glulisine", + "class": "Antidiabetic", + "subclass": "Prandial Insulin", + "category": "Endocrinology - Insulins & Injectables", + "accent": "#16a34a", + "tag": "INSULIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "10-15 mins", + "cls": "warn", + "flag": "" + }, + { + "label": "Timing", + "value": "WITH MEALS", + "cls": "good", + "flag": "" + }, + { + "label": "Hypoglycemia", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-rapid-acting mealtime insulin. Functionally equivalent to Aspart and Lispro, providing immediate post-prandial glucose control.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated dynamically.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be injected just before or within 20 mins of starting a meal.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Insulin glulisine is a rapid-acting mealtime insulin alternative to aspart and lispro, but offers no clear advantage and is less widely prescribed.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Hypoglycemia, hypokalemia.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Lipohypertrophy.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Meal Coverage", + "val": "**SC** Administer 0-15 mins before a meal or soon after starting.", + "tags": [] + }, + { + "key": "Continuous Subcutaneous Insulin Infusion (CSII)", + "val": "Widely used in insulin pumps due to its rapid kinetics.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Apidra", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled pens for **SC** injection (100 U/mL). Clear solution.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 1 and Type 2 Diabetes.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Interchangeable rapid-acting analogue. Choice usually depends on endocrinologist preference or state contracts.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active hypoglycemia.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3 (Aspart/Lispro have Category A status, making them preferred in pregnancy).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Insulin glulisine pregnancy row is Category B3/caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Corticosteroids, Beta-blockers.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Pre-meal **BSL**. Ensure food is eaten promptly.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Pump Block", + "val": "Historically, Glulisine was noted to crystallize/block the tubing of insulin pumps slightly more frequently than Aspart, though modern pump tech has mitigated this. If a pump patient presents in DKA, always check the line for occlusions.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Asparagine at position B3 replaced by lysine, and lysine at B29 replaced by glutamic acid. Prevents hexamer formation, ensuring immediate monomer absorption.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 10-15 mins.", + "tags": [] + }, + { + "key": "Peak", + "val": "1 hour.", + "tags": [] + }, + { + "key": "Duration", + "val": "2-4 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - APIDRA ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Prandial Insulin — Ultra-rapid-acting mealtime insulin." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled pens for **SC** injection (100 U/mL). Clear solution. (Apidra)" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** Administer 0-15 mins before a meal or soon after starting. Titrated dynamically." + }, + { + "label": "Key Indication Doses", + "value": "Meal Coverage: **SC** Administer 0-15 mins before a meal or soon after starting. Continuous Subcutaneous Insulin Infusion (CSII): Widely used in insulin pumps due to its rapid kinetics." + }, + { + "label": "Best Uses", + "value": "Insulin glulisine is a rapid-acting mealtime insulin alternative to aspart and lispro, but offers no clear advantage and is less widely prescribed." + }, + { + "label": "Avoid / Cautions", + "value": "Active hypoglycemia. **Pregnancy** Category B3 (Aspart/Lispro have Category A status, making them preferred in pregnancy)." + }, + { + "label": "Key Risks", + "value": "Metabolic: Hypoglycemia, hypokalemia. Dermatological: Lipohypertrophy." + }, + { + "label": "Key Interactions", + "value": "Corticosteroids, Beta-blockers." + }, + { + "label": "Monitoring", + "value": "Pre-meal **BSL**. Ensure food is eaten promptly." + }, + { + "label": "Clinical Pearl", + "value": "Historically, Glulisine was noted to crystallize/block the tubing of insulin pumps slightly more frequently than Aspart, though modern pump tech has mitigated this. If a pump patient presents in DKA, always check the line for occlusions." + } + ] + }, + { + "slug": "insulin-lispro", + "name": "Insulin lispro", + "class": "Antidiabetic", + "subclass": "Prandial Insulin", + "category": "Endocrinology - Insulins & Injectables", + "accent": "#16a34a", + "tag": "INSULIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "15 mins", + "cls": "warn", + "flag": "" + }, + { + "label": "Timing", + "value": "WITH MEALS", + "cls": "good", + "flag": "" + }, + { + "label": "Hypoglycemia", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-rapid-acting mealtime (prandial) insulin. Functionally identical in clinical use to Insulin Aspart (NovoRapid). Used to cover mealtime carbohydrate spikes or correct high sugars.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated dynamically.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be injected within 15 minutes before or immediately after a meal. Delaying food will cause a severe hypo.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Insulin lispro is a rapid-acting mealtime insulin interchangeable with insulin aspart, but requires injection immediately before meals and carries significant hypoglycaemia risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Hypoglycemia, weight gain, hypokalemia.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Lipohypertrophy.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Mealtime Coverage", + "val": "**SC** Administer 0-15 mins before a meal. Dose varies by carb counting or fixed regimens.", + "tags": [] + }, + { + "key": "IV Infusion / DKA", + "val": "**IV** Regular insulin is preferred, but rapid analogues can be used in emergencies.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Humalog, Lyumjev (ultra-fast)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled pens or cartridges for **SC** injection (100 U/mL, 200 U/mL). Clear solution.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 1 and Type 2 Diabetes.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The 'Bolus' in the basal-bolus regimen. Highly interchangeable with Aspart based on hospital formulary.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active hypoglycemia.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Insulin lispro pregnancy row is Category A/safe and should not trigger a contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers (masks hypos), steroids (causes resistance).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the food is physically in front of the patient before administering. Pre-meal **BSL** check.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 200 Unit Trap", + "val": "Humalog comes in a highly concentrated 200 U/mL pen. The pen clicker automatically does the math (1 click = 1 unit). However, if a nurse draws liquid *out* of this pen with a standard 100 U/mL syringe, they will give the patient a double lethal dose. Never draw from a 200 U/mL pen.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Amino acids lysine and proline at positions 28 and 29 are reversed. This prevents the molecules from binding into hexamers, allowing immediate absorption as single monomers into the blood.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 10-15 mins. (Lyumjev is even faster due to added vasodilators).", + "tags": [] + }, + { + "key": "Peak", + "val": "1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "2-5 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - HUMALOG ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Prandial Insulin — Ultra-rapid-acting mealtime (prandial) insulin." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled pens or cartridges for **SC** injection (100 U/mL, 200 U/mL). Clear solution. (Humalog, Lyumjev (ultra-fast))" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** Administer 0-15 mins before a meal. Dose varies by carb counting or fixed regimens. Titrated dynamically." + }, + { + "label": "Key Indication Doses", + "value": "Mealtime Coverage: **SC** Administer 0-15 mins before a meal. Dose varies by carb counting or fixed regimens. IV Infusion / DKA: **IV** Regular insulin is preferred, but rapid analogues can be used in emergencies." + }, + { + "label": "Best Uses", + "value": "Insulin lispro is a rapid-acting mealtime insulin interchangeable with insulin aspart, but requires injection immediately before meals and carries significant hypoglycaemia risk." + }, + { + "label": "Avoid / Cautions", + "value": "Active hypoglycemia. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Metabolic: Hypoglycemia, weight gain, hypokalemia. Dermatological: Lipohypertrophy." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers (masks hypos), steroids (causes resistance)." + }, + { + "label": "Monitoring", + "value": "Ensure the food is physically in front of the patient before administering. Pre-meal **BSL** check." + }, + { + "label": "Clinical Pearl", + "value": "Humalog comes in a highly concentrated 200 U/mL pen. The pen clicker automatically does the math (1 click = 1 unit). However, if a nurse draws liquid *out* of this pen with a standard 100 U/mL syringe, they will give the patient a double lethal dose. Never draw from a 200 U/mL pen." + } + ] + }, + { + "slug": "novomix-30", + "name": "Novomix 30", + "class": "Antidiabetic", + "subclass": "Biphasic Insulin", + "category": "Endocrinology - Insulins & Injectables", + "accent": "#16a34a", + "tag": "INSULIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Composition", + "value": "30% FAST / 70% SLOW", + "cls": "warn", + "flag": "" + }, + { + "label": "Timing", + "value": "STRICTLY BD", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Hypo Risk", + "value": "HIGH MID-DAY", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Pre-mixed biphasic insulin. Contains 30% rapid-acting insulin (Aspart) to cover the meal, and 70% intermediate-acting insulin (Protamine Aspart) to provide background coverage.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated based on BSL.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The patient is locked into a rigid eating schedule. Because the 70% slow portion peaks later in the day, if they skip lunch, they will suffer a severe hypo.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Novomix 30 is a biphasic insulin combining rapid and intermediate-acting components for simplified regimens, but offers less flexibility than basal-bolus and increases hypoglycaemia risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Hypoglycemia. The rigid profile makes snacking mandatory. HIGH — Weight gain.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes", + "val": "**SC** Administered **BD** (Usually immediately before Breakfast and before Dinner). Doses are titrated to morning and evening BSLs.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "NovoMix 30", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled pens (100 U/mL). Cloudy, white suspension. MUST BE ROLLED/MIXED before injection.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 1 and Type 2 Diabetes.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Used heavily in Type 2 diabetics who require insulin but refuse to do 4 injections a day (Basal-Bolus). Reduces injection burden to 2 per day.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active hypoglycemia. IV administration (The protamine crystals will cause massive fatal microemboli in the blood).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "NovoMix 30 pregnancy row is Category A/safe and should not trigger a contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers, steroids.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the pen is inverted/rolled 10 times until the cloudy liquid is uniformly white. Injecting the clear liquid at the top gives pure fast insulin (causing a fatal hypo), leaving pure slow insulin at the bottom.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Lunchtime Crash", + "val": "A patient takes NovoMix at 8 AM for breakfast. The 70% slow component peaks right around 1 PM. If they don't eat lunch, they will crash into a severe hypo. They MUST eat 3 meals a day.", + "tags": [] + }, + { + "key": "The Titration Trap", + "val": "If a patient on NovoMix 30 BD has a high BSL at lunch, you CANNOT just give them an extra shot of NovoMix to correct it. Doing so gives them another dose of the 70% slow insulin, which will stack up and kill them overnight.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "30% soluble Insulin Aspart (rapid peak for the meal). 70% Insulin Aspart crystallized with Protamine (slowly dissolves over 12 hours for background coverage).", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 10-20 mins (from the 30% fast component).", + "tags": [] + }, + { + "key": "Peak", + "val": "Dual peaks: 1-4 hours (fast) and 4-12 hours (slow).", + "tags": [] + }, + { + "key": "Duration", + "val": "14-24 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - NOVOMIX 30 ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Biphasic Insulin — Pre-mixed biphasic insulin." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled pens (100 U/mL). Cloudy, white suspension. MUST BE ROLLED/MIXED before injection. (NovoMix 30)" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** Administered **BD** (Usually immediately before Breakfast and before Dinner). Doses are titrated to morning and evening BSLs. Titrated based on BSL." + }, + { + "label": "Best Uses", + "value": "Novomix 30 is a biphasic insulin combining rapid and intermediate-acting components for simplified regimens, but offers less flexibility than basal-bolus and increases hypoglycaemia risk." + }, + { + "label": "Avoid / Cautions", + "value": "Active hypoglycemia. IV administration (The protamine crystals will cause massive fatal microemboli in the blood). **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Metabolic: Hypoglycemia. The rigid profile makes snacking mandatory. HIGH — Weight gain." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers, steroids." + }, + { + "label": "Monitoring", + "value": "Ensure the pen is inverted/rolled 10 times until the cloudy liquid is uniformly white. Injecting the clear liquid at the top gives pure fast insulin (causing a fatal hypo), leaving pure slow insulin at the bottom." + }, + { + "label": "Clinical Pearl", + "value": "A patient takes NovoMix at 8 AM for breakfast. The 70% slow component peaks right around 1 PM. If they don't eat lunch, they will crash into a severe hypo. They MUST eat 3 meals a day." + } + ] + }, + { + "slug": "semaglutide", + "name": "Semaglutide", + "class": "Antidiabetic", + "subclass": "GLP-1 Agonist", + "category": "Endocrinology - Insulins & Injectables", + "accent": "#16a34a", + "tag": "GLP-1", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "2.4 mg/week", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1 WEEK", + "cls": "good", + "flag": "" + }, + { + "label": "Weight Loss", + "value": "MASSIVE", + "cls": "good", + "flag": "" + }, + { + "label": "Pancreatitis", + "value": "RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The most potent GLP-1 agonist available. Provides unparalleled weight loss and cardiovascular mortality benefits. Dosed once weekly.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1 mg/week** (Ozempic for Diabetes) or **2.4 mg/week** (Wegovy for Weight Loss).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Drastically slows gastric emptying. Anaesthetists require the drug to be withheld prior to surgery to prevent fatal pulmonary aspiration under anaesthesia.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Semaglutide is the most potent GLP-1 agonist with landmark cardiovascular and weight loss outcomes, but causes significant GI side effects and is contraindicated in personal/family history of medullary thyroid carcinoma.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea (up to 45%), vomiting, diarrhea, severe constipation. CRITICAL — Acute pancreatitis, gastroparesis, bowel obstruction/ileus.", + "tags": [] + }, + { + "key": "Endocrine", + "val": "MODERATE — Medullary thyroid carcinoma (seen in rodents, theoretical risk in humans).", + "tags": [] + }, + { + "key": "Renal", + "val": "MODERATE — AKI secondary to severe dehydration from vomiting.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes (Ozempic)", + "val": "**SC** 0.25 mg once weekly for 4 weeks. Increase to 0.5 mg weekly. Max 1 mg/week.", + "tags": [] + }, + { + "key": "Weight Loss (Wegovy)", + "val": "**SC** Titrated slowly over 5 months from 0.25 mg up to 2.4 mg once weekly.", + "tags": [] + }, + { + "key": "Type 2 Diabetes (Oral Rybelsus)", + "val": "**PO** 3 mg **OD** for 1 month, then 7 mg **OD**. Max 14 mg/day. (MUST take with 120mL water on an empty stomach, wait 30 mins before eating).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Ozempic (T2DM), Wegovy (Obesity), Rybelsus (Oral)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled multi-dose pens for **SC** injection.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for Ozempic. Private script for Wegovy.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 2 Diabetes, Obesity (BMI > 30, or > 27 with comorbidities), reduction of major cardiovascular events.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The blockbuster drug of modern endocrinology. Revolutionizing the treatment of obesity and diabesity.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Personal/family history of Medullary Thyroid Carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). History of pancreatitis.", + "tags": [] + }, + { + "key": "Surgery", + "val": "MANDATORY — Withhold for 1-2 weeks prior to elective surgery involving general anaesthesia due to retained gastric contents and aspiration risk.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Must be ceased 2 months before planned conception.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "MODERATE — Delays the absorption of rapidly acting oral medications due to gastric stasis.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Counsel patients to eat tiny portions. If they eat a normal-sized heavy meal, the delayed stomach emptying will cause them to vomit it back up.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **HbA1c**, **Weight**, and **U&E**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Oral Miracle", + "val": "Rybelsus is a pharmacological miracle. GLP-1 is a peptide that is instantly destroyed by stomach acid. Rybelsus contains an absorption enhancer (SNAC) that locally buffers stomach acid and forces the peptide across the gastric wall. However, if the patient takes it with more than half a glass of water, or eats within 30 minutes, the SNAC is washed away and absorption is ZERO.", + "tags": [] + }, + { + "key": "The Ozempic Face", + "val": "Rapid, massive weight loss causes a loss of facial buccal fat, leading to a gaunt, aged appearance colloquially known as 'Ozempic face'.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "GLP-1 analogue with 94% homology to human GLP-1. Bound to a fatty acid chain that locks it to albumin in the blood, preventing degradation by DPP-4 and drastically extending its half-life. Drops appetite, slows gut, boosts insulin.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Steady state takes 4-5 weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1 WEEK (approx 165 hours).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - OZEMPIC TGA evidence, PBS search, and TGA GLP-1 aspiration warning checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "GLP-1 Agonist — The most potent GLP-1 agonist available." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled multi-dose pens for **SC** injection. (Ozempic (T2DM), Wegovy (Obesity), Rybelsus (Oral))" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** 0.25 mg once weekly for 4 weeks. Increase to 0.5 mg weekly. Max 1 mg/week." + }, + { + "label": "Key Indication Doses", + "value": "Type 2 Diabetes (Ozempic): **SC** 0.25 mg once weekly for 4 weeks. Increase to 0.5 mg weekly. Max 1 mg/week. Weight Loss (Wegovy): **SC** Titrated slowly over 5 months from 0.25 mg up to 2.4 mg once weekly. Type 2 Diabetes (Oral Rybelsus): **PO** 3 mg **OD** for 1 month, then 7 mg **OD**. Max 14 mg/day. (MUST take with 120mL water on an empty stomach, wait 30 mins before eating)." + }, + { + "label": "Best Uses", + "value": "Semaglutide is the most potent GLP-1 agonist with landmark cardiovascular and weight loss outcomes, but causes significant GI side effects and is contraindicated in personal/family history of medullary thyroid carcinoma." + }, + { + "label": "Avoid / Cautions", + "value": "Personal/family history of Medullary Thyroid Carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). History of pancreatitis. **Pregnancy** Category D. Must be ceased 2 months before planned conception." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea (up to 45%), vomiting, diarrhea, severe constipation. CRITICAL — Acute pancreatitis, gastroparesis, bowel obstruction/ileus. Endocrine: Medullary thyroid carcinoma (seen in rodents, theoretical risk in humans). Renal: AKI secondary to severe dehydration from vomiting." + }, + { + "label": "Key Interactions", + "value": "Delays the absorption of rapidly acting oral medications due to gastric stasis." + }, + { + "label": "Monitoring", + "value": "Counsel patients to eat tiny portions. If they eat a normal-sized heavy meal, the delayed stomach emptying will cause them to vomit it back up. Routine **HbA1c**, **Weight**, and **U&E**." + }, + { + "label": "Clinical Pearl", + "value": "Rybelsus is a pharmacological miracle. GLP-1 is a peptide that is instantly destroyed by stomach acid. Rybelsus contains an absorption enhancer (SNAC) that locally buffers stomach acid and forces the peptide across the gastric wall. However, if the patient takes it with more than half a glass of water, or eats within 30 minutes, the SNAC is washed away and absorption is ZERO." + } + ] + }, + { + "slug": "acarbose", + "name": "Acarbose", + "class": "Antidiabetic", + "subclass": "Alpha-Glucosidase Inhibitor", + "category": "Endocrinology - Oral Antidiabetics", + "accent": "#16a34a", + "tag": "ORAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "Flatulence", + "value": "SEVERE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Timing", + "value": "FIRST BITE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Alpha-glucosidase inhibitor. Acts entirely in the gut to delay the digestion of complex carbohydrates. Blunts post-meal glucose spikes but causes horrific flatulence.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg/day** (100 mg TDS with meals).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "If the patient experiences a 'hypo' while on this drug (due to another med like insulin), you MUST give them pure glucose (jellybeans/dextrose). Table sugar (sucrose) will not work because the drug blocks its digestion.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Acarbose is an alpha-glucosidase inhibitor that reduces postprandial glucose spikes, but causes significant flatulence and GI intolerance limiting adherence.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Severe flatulence (farting), bloating, abdominal pain, diarrhea. Occurs because the undigested carbohydrates pass into the colon, where bacteria ferment them into massive amounts of gas.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "MODERATE — Rare transaminitis at max doses.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes", + "val": "Start **PO** 50 mg **OD** to **TDS**. Titrate very slowly to 100 mg **TDS**. MUST be taken with the first bite of the main meal.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Avoid if **eGFR** < 25.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Glucobay", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (50 mg, 100 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 2 Diabetes (specifically for patients with high post-prandial glucose spikes).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Rarely used as first-line therapy anymore due to severe GI intolerance, but highly effective for isolated post-meal spikes.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Inflammatory Bowel Disease (IBD), partial bowel obstruction, severe hernias (gas distension is dangerous).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Acarbose pregnancy row is Category B3/caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Antacids and digestive enzymes (e.g., Creon) will alter or abolish its effect.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the patient takes it EXACTLY with the first mouthful of food. If taken 30 mins before or after the meal, it does absolutely nothing.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **HbA1c**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Sucrose Trap", + "val": "Acarbose blocks the enzyme that splits sucrose (table sugar/candy) into glucose. If a patient on Acarbose and Gliclazide goes 'hypo', giving them a chocolate bar or table sugar will fail to raise their blood sugar. They MUST be given pure Dextrose tablets or Glucose gel, which require no digestion.", + "tags": [] + }, + { + "key": "The Social Side Effect", + "val": "The flatulence is so severe and socially debilitating that up to 50% of patients abandon the drug. Titrating the dose up over months (starting at 50mg OD) helps the gut bacteria adapt.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitively inhibits alpha-glucosidase enzymes in the brush border of the small intestine. This prevents the breakdown of complex carbohydrates (starches) into monosaccharides, delaying glucose absorption and smoothing out the blood sugar curve.", + "tags": [] + }, + { + "key": "Onset", + "val": "Immediate (acts locally on the meal).", + "tags": [] + }, + { + "key": "Half-life", + "val": "2 hours. Systemic absorption is < 2%. Acts almost entirely in the gut lumen.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ACARBOSE VIATRIS ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha-Glucosidase Inhibitor — Alpha-glucosidase inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (50 mg, 100 mg). (Glucobay)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 50 mg **OD** to **TDS**. Titrate very slowly to 100 mg **TDS**. MUST be taken with the first bite of the main meal. Max **300 mg/day** (100 mg TDS with meals)." + }, + { + "label": "Key Indication Doses", + "value": "Type 2 Diabetes: Start **PO** 50 mg **OD** to **TDS**. Titrate very slowly to 100 mg **TDS**. MUST be taken with the first bite of the main meal. Renal Impairment: Avoid if **eGFR** < 25." + }, + { + "label": "Best Uses", + "value": "Acarbose is an alpha-glucosidase inhibitor that reduces postprandial glucose spikes, but causes significant flatulence and GI intolerance limiting adherence." + }, + { + "label": "Avoid / Cautions", + "value": "Inflammatory Bowel Disease (IBD), partial bowel obstruction, severe hernias (gas distension is dangerous). **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe flatulence (farting), bloating, abdominal pain, diarrhea. Occurs because the undigested carbohydrates pass into the colon, where bacteria ferment them into massive amounts of gas. Hepatic: Rare transaminitis at max doses." + }, + { + "label": "Key Interactions", + "value": "Antacids and digestive enzymes (e.g., Creon) will alter or abolish its effect." + }, + { + "label": "Monitoring", + "value": "Ensure the patient takes it EXACTLY with the first mouthful of food. If taken 30 mins before or after the meal, it does absolutely nothing. Routine **HbA1c**." + }, + { + "label": "Clinical Pearl", + "value": "Acarbose blocks the enzyme that splits sucrose (table sugar/candy) into glucose. If a patient on Acarbose and Gliclazide goes 'hypo', giving them a chocolate bar or table sugar will fail to raise their blood sugar. They MUST be given pure Dextrose tablets or Glucose gel, which require no digestion." + } + ] + }, + { + "slug": "dapagliflozin", + "name": "Dapagliflozin", + "class": "Antidiabetic", + "subclass": "SGLT2 Inhibitor", + "category": "Endocrinology - Oral Antidiabetics", + "accent": "#16a34a", + "tag": "ORAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "13 h", + "cls": "", + "flag": "" + }, + { + "label": "Euglycemic DKA", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Heart Failure", + "value": "INDICATED", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "SGLT2 inhibitor. Forces the kidneys to pee out glucose. Provides massive, independent mortality benefits in Heart Failure (HFrEF and HFpEF) and Chronic Kidney Disease.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Carries a lethal risk of Euglycemic Diabetic Ketoacidosis (DKA with a normal blood sugar). Must be ceased during acute illness or surgery.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dapagliflozin is an SGLT2 inhibitor with proven heart failure and CKD benefits independent of diabetes, but carries the same class risks of euglycaemic DKA and genital infections.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Euglycemic DKA. The patient starves at a cellular level, generating ketones, but the BSL looks normal because the kidneys are hiding the sugar in the urine.", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "HIGH — Genital mycotic infections (thrush), UTIs. CRITICAL — Fournier's gangrene (rare necrotising fasciitis of the perineum).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Hypovolemia, orthostatic hypotension (due to osmotic diuresis).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes / Heart Failure / CKD", + "val": "**PO** 10 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — For diabetes control, initiate only if **eGFR** > 45. For Heart Failure/CKD protection, can be initiated down to an **eGFR** of 25.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Forxiga, Xigduo (combo with metformin)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 2 Diabetes, Heart Failure (all ejection fractions), Chronic Kidney Disease.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Standard of care for cardiac and renal protection. Often prescribed by cardiologists/nephrologists rather than just endocrinologists.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Type 1 Diabetes (DKA risk is too high).", + "tags": [] + }, + { + "key": "Surgery", + "val": "MANDATORY — Must be withheld for 3 DAYS prior to major surgery or bowel prep to prevent perioperative DKA.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive hypotension and dehydration if combined with Loop or Thiazide diuretics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — 'Sick Day Rules': Cease immediately if the patient is vomiting, fasting, or has a severe infection. Check blood KETONES (not just BSL) if unwell.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor **U&E** and **eGFR**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Ketone Check", + "val": "If a patient on Forxiga feels nauseous and breathless in the ED, and their BSL is a perfect 6.0 mmol/L, do NOT send them home. You MUST check blood ketones or an ABG. If ketones are high, they are in DKA and need IV insulin and dextrose instantly.", + "tags": [] + }, + { + "key": "The Hygiene Rule", + "val": "Sugar-rich urine is a breeding ground for yeast. Strict daily perineal hygiene is required to prevent relentless, severe thrush.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits SGLT2 in the proximal renal tubule. Blocks glucose reabsorption, forcing ~70g of glucose into the urine daily. Also lowers intraglomerular pressure (protecting kidneys) and reduces cardiac preload/afterload.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "13 hours. Primarily metabolised via glucuronidation.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - FORXIGA ARTG, TGA PI evidence, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGLT2 Inhibitor — SGLT2 inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg). (Forxiga, Xigduo (combo with metformin))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10 mg **OD**. Max **10 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Type 2 Diabetes / Heart Failure / CKD: **PO** 10 mg **OD**. Renal Impairment: For diabetes control, initiate only if **eGFR** > 45. For Heart Failure/CKD protection, can be initiated down to an **eGFR** of 25." + }, + { + "label": "Best Uses", + "value": "Dapagliflozin is an SGLT2 inhibitor with proven heart failure and CKD benefits independent of diabetes, but carries the same class risks of euglycaemic DKA and genital infections." + }, + { + "label": "Avoid / Cautions", + "value": "Type 1 Diabetes (DKA risk is too high). **Pregnancy** Category D." + }, + { + "label": "Key Risks", + "value": "Metabolic: Euglycemic DKA. The patient starves at a cellular level, generating ketones, but the BSL looks normal because the kidneys are hiding the sugar in the urine. Genitourinary: Genital mycotic infections (thrush), UTIs. CRITICAL — Fournier's gangrene (rare necrotising fasciitis of the perineum). Cardiovascular: Hypovolemia, orthostatic hypotension (due to osmotic diuresis)." + }, + { + "label": "Key Interactions", + "value": "Additive hypotension and dehydration if combined with Loop or Thiazide diuretics." + }, + { + "label": "Monitoring", + "value": "'Sick Day Rules': Cease immediately if the patient is vomiting, fasting, or has a severe infection. Check blood KETONES (not just BSL) if unwell. Monitor **U&E** and **eGFR**." + }, + { + "label": "Clinical Pearl", + "value": "If a patient on Forxiga feels nauseous and breathless in the ED, and their BSL is a perfect 6.0 mmol/L, do NOT send them home. You MUST check blood ketones or an ABG. If ketones are high, they are in DKA and need IV insulin and dextrose instantly." + } + ] + }, + { + "slug": "empagliflozin", + "name": "Empagliflozin", + "class": "Antidiabetic", + "subclass": "SGLT2 Inhibitor", + "category": "Endocrinology - Oral Antidiabetics", + "accent": "#16a34a", + "tag": "ORAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "25 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12 h", + "cls": "", + "flag": "" + }, + { + "label": "Euglycemic DKA", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Thrush/UTI", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "SGLT2 inhibitor. Forces the kidneys to excrete glucose in the urine. Revolutionary drug providing massive mortality benefits in Heart Failure and CKD, independent of its diabetes effect.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **25 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Can cause life-threatening Diabetic Ketoacidosis (DKA) while the blood glucose appears completely normal (Euglycemic DKA).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Empagliflozin is an SGLT2 inhibitor with landmark cardiovascular and renal outcome benefits in diabetes and heart failure, but carries risk of euglycaemic DKA, genital mycotic infections, and Fournier's gangrene.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Euglycemic DKA. The patient goes into ketoacidosis from severe insulin starvation, but the blood sugar looks fine because the kidneys are peeing it all out.", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "HIGH — Genital mycotic infections (severe thrush), complicated UTIs. CRITICAL — Fournier's gangrene (necrotising fasciitis of the perineum).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Hypovolemia, orthostatic hypotension (due to osmotic diuresis).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes", + "val": "**PO** 10 mg **OD**. May increase to 25 mg **OD**.", + "tags": [] + }, + { + "key": "Heart Failure (HFrEF/HFpEF) / CKD", + "val": "**PO** 10 mg **OD** (Dose does not need escalating for cardiac/renal benefits).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Ineffective for glucose lowering if **eGFR** < 45, but safely continued down to **eGFR** 20 strictly for cardio/renal protection.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Jardiance, Jardiamet (combo)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg, 25 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for T2DM, HFrEF, and CKD.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 2 Diabetes, Heart Failure (regardless of ejection fraction), Chronic Kidney Disease.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Standard of care. One of the 'Four Pillars' of heart failure therapy.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Type 1 Diabetes (extremely high DKA risk).", + "tags": [] + }, + { + "key": "Surgery", + "val": "MANDATORY — Must be withheld for 3 DAYS prior to major surgery or periods of severe acute illness/starvation to prevent perioperative DKA.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive hypovolemia/hypotension if combined with Loop or Thiazide diuretics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — 'Sick Day Rules': Cease immediately if vomiting, fasting, or severely unwell. Check blood ketones (not just BSL) if unwell.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor **U&E** and **eGFR**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Ketone Check", + "val": "If a patient on Jardiance presents to ED vomiting and unwell, a normal BSL does NOT rule out DKA. You MUST check a capillary blood ketone level or an ABG. If ketones are > 1.5, treat as DKA.", + "tags": [] + }, + { + "key": "The Hygiene Rule", + "val": "Because the urine is saturated with sugar, bacteria and yeast thrive. Excellent perineal hygiene is mandatory to prevent relentless thrush.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits the Sodium-Glucose Co-Transporter 2 (SGLT2) in the proximal renal tubule. Blocks glucose reabsorption, causing 70+ grams of glucose to be peed out daily. Also induces a mild osmotic diuresis and lowers intraglomerular pressure.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** Hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - JARDIANCE ARTG, TGA AusPAR/PI evidence, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGLT2 Inhibitor — SGLT2 inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg, 25 mg). (Jardiance, Jardiamet (combo))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10 mg **OD**. May increase to 25 mg **OD**. Max **25 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Type 2 Diabetes: **PO** 10 mg **OD**. May increase to 25 mg **OD**. Heart Failure (HFrEF/HFpEF) / CKD: **PO** 10 mg **OD** (Dose does not need escalating for cardiac/renal benefits). Renal Impairment: Ineffective for glucose lowering if **eGFR** < 45, but safely continued down to **eGFR** 20 strictly for cardio/renal protection." + }, + { + "label": "Best Uses", + "value": "Empagliflozin is an SGLT2 inhibitor with landmark cardiovascular and renal outcome benefits in diabetes and heart failure, but carries risk of euglycaemic DKA, genital mycotic infections, and Fournier's gangrene." + }, + { + "label": "Avoid / Cautions", + "value": "Type 1 Diabetes (extremely high DKA risk). **Pregnancy** Category D." + }, + { + "label": "Key Risks", + "value": "Metabolic: Euglycemic DKA. The patient goes into ketoacidosis from severe insulin starvation, but the blood sugar looks fine because the kidneys are peeing it all out. Genitourinary: Genital mycotic infections (severe thrush), complicated UTIs. CRITICAL — Fournier's gangrene (necrotising fasciitis of the perineum). Cardiovascular: Hypovolemia, orthostatic hypotension (due to osmotic diuresis)." + }, + { + "label": "Key Interactions", + "value": "Additive hypovolemia/hypotension if combined with Loop or Thiazide diuretics." + }, + { + "label": "Monitoring", + "value": "'Sick Day Rules': Cease immediately if vomiting, fasting, or severely unwell. Check blood ketones (not just BSL) if unwell. Monitor **U&E** and **eGFR**." + }, + { + "label": "Clinical Pearl", + "value": "If a patient on Jardiance presents to ED vomiting and unwell, a normal BSL does NOT rule out DKA. You MUST check a capillary blood ketone level or an ABG. If ketones are > 1.5, treat as DKA." + } + ] + }, + { + "slug": "gliclazide", + "name": "Gliclazide", + "class": "Antidiabetic", + "subclass": "Sulfonylurea", + "category": "Endocrinology - Oral Antidiabetics", + "accent": "#16a34a", + "tag": "ORAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "120 mg MR/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "16 h", + "cls": "", + "flag": "" + }, + { + "label": "Hypoglycemia", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Weight Gain", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Second-generation sulfonylurea. Forces the pancreas to pump out insulin regardless of blood glucose levels. Highly effective but carries a massive risk of hypoglycemia.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **120 mg/day** (Modified Release) or **320 mg/day** (Immediate Release).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be taken with a meal. If the patient skips a meal, they will suffer a severe hypo.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Gliclazide is a sulfonylurea with proven efficacy for type 2 diabetes and lower hypoglycaemia risk than glibenclamide, but causes weight gain and hypoglycaemia especially in elderly and renal impairment.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — Severe, prolonged hypoglycemia (can be fatal in the elderly). HIGH — Weight gain (insulin is an anabolic, fat-storing hormone).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "LOW — Mild nausea.", + "tags": [] + }, + { + "key": "Immunological", + "val": "MODERATE — Sulfa-allergy cross-reactivity (rash).", + "tags": [], + "patient": { + "factors": ["allergy-sulfa"], + "action": "caution", + "severity": "caution", + "note": "Gliclazide sulfonamide-allergy row should not trigger penicillin-allergy alerts." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes (MR)", + "val": "**PO** 30-120 mg **OD** with breakfast.", + "tags": [] + }, + { + "key": "Type 2 Diabetes (IR)", + "val": "**PO** 40-160 mg **BD** with meals.", + "tags": [] + }, + { + "key": "Elderly / Renal Impairment", + "val": "Start at 30 mg MR. Highly sensitive to prolonged hypoglycemia.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Diamicron, Diamicron MR", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets IR (80 mg). Modified Release Tablets (30 mg, 60 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 2 Diabetes Mellitus.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Second-line agent after metformin. Rapidly lowers HbA1c but promotes weight gain and pancreatic burnout over time.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Type 1 Diabetes (requires functioning beta-cells to work), Diabetic Ketoacidosis (DKA).", + "tags": [] + }, + { + "key": "Renal / Hepatic", + "val": "HIGH — Avoid in severe renal (**eGFR** < 30) or hepatic failure due to drug accumulation leading to profound hypos.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Avoid gliclazide in severe renal or hepatic failure." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. Causes severe neonatal hypoglycemia.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation", "paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers mask the physiological warning signs of a hypo (tremor, tachycardia), leaving only sweating as a warning sign. The patient may collapse without realizing their BSL dropped.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Regular **BSL** checks on the ward. Withhold if the patient is NBM (Nil By Mouth).", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **HbA1c** and **U&E**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The NBM Trap", + "val": "If a patient on Gliclazide is made 'Nil By Mouth' for surgery or a scan, you MUST withhold their morning dose. The drug forces insulin release regardless of food intake; they will crash.", + "tags": [] + }, + { + "key": "The Pancreatic Burnout", + "val": "Sulfonylureas essentially whip a tired horse (the failing pancreas). Over 5-10 years, they accelerate beta-cell destruction, eventually forcing the patient onto injectable insulin.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to sulfonylurea receptors on pancreatic beta-cells, closing ATP-sensitive potassium channels. This depolarizes the cell, forcing calcium influx and massive insulin exocytosis.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h (MR).", + "tags": [] + }, + { + "key": "Half-life", + "val": "16 hours (Metabolised hepatically, renally cleared).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - GLICLAZIDE MR ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Sulfonylurea — Second-generation sulfonylurea." + }, + { + "label": "Route / Formulation", + "value": "Tablets IR (80 mg). Modified Release Tablets (30 mg, 60 mg). (Diamicron, Diamicron MR)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 30-120 mg **OD** with breakfast. Max **120 mg/day** (Modified Release) or **320 mg/day** (Immediate Release)." + }, + { + "label": "Key Indication Doses", + "value": "Type 2 Diabetes (MR): **PO** 30-120 mg **OD** with breakfast. Type 2 Diabetes (IR): **PO** 40-160 mg **BD** with meals. Elderly / Renal Impairment: Start at 30 mg MR. Highly sensitive to prolonged hypoglycemia." + }, + { + "label": "Best Uses", + "value": "Gliclazide is a sulfonylurea with proven efficacy for type 2 diabetes and lower hypoglycaemia risk than glibenclamide, but causes weight gain and hypoglycaemia especially in elderly and renal impairment." + }, + { + "label": "Avoid / Cautions", + "value": "Type 1 Diabetes (requires functioning beta-cells to work), Diabetic Ketoacidosis (DKA). **Pregnancy** Category C. Causes severe neonatal hypoglycemia." + }, + { + "label": "Key Risks", + "value": "Endocrine: Severe, prolonged hypoglycemia (can be fatal in the elderly). HIGH — Weight gain (insulin is an anabolic, fat-storing hormone). Gastrointestinal: Mild nausea. Immunological: Sulfa-allergy cross-reactivity (rash)." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers mask the physiological warning signs of a hypo (tremor, tachycardia), leaving only sweating as a warning sign. The patient may collapse without realizing their BSL dropped." + }, + { + "label": "Monitoring", + "value": "Regular **BSL** checks on the ward. Withhold if the patient is NBM (Nil By Mouth). Routine **HbA1c** and **U&E**." + }, + { + "label": "Clinical Pearl", + "value": "If a patient on Gliclazide is made 'Nil By Mouth' for surgery or a scan, you MUST withhold their morning dose. The drug forces insulin release regardless of food intake; they will crash." + } + ] + }, + { + "slug": "glipizide", + "name": "Glipizide", + "class": "Antidiabetic", + "subclass": "Sulfonylurea", + "category": "Endocrinology - Oral Antidiabetics", + "accent": "#16a34a", + "tag": "ORAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "40 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-4 h", + "cls": "", + "flag": "" + }, + { + "label": "Hypoglycemia", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Short-acting, second-generation sulfonylurea. Forces insulin secretion from the pancreas. Shorter half-life than Gliclazide, making it slightly safer regarding prolonged hypoglycemia, but requires multiple daily doses.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **40 mg/day** (Doses > 15 mg should be divided).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be taken 30 minutes before a meal. If the patient skips the meal, they will suffer a severe hypoglycemic crash.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Glipizide is a short-acting sulfonylurea for type 2 diabetes, but causes hypoglycaemia and weight gain and has largely been replaced by newer agents with better safety profiles.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — Severe hypoglycemia. HIGH — Weight gain (anabolic insulin effect).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Nausea, diarrhea.", + "tags": [] + }, + { + "key": "Immunological", + "val": "MODERATE — Sulfa-allergy cross-reactivity.", + "tags": [], + "patient": { + "factors": ["allergy-sulfa"], + "action": "caution", + "severity": "caution", + "note": "Glipizide sulfonamide-allergy row should not trigger penicillin-allergy alerts." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes", + "val": "Start **PO** 5 mg **OD** (30 mins before breakfast). Titrate by 2.5-5 mg every few days. Doses > 15 mg/day must be given **BD**.", + "tags": [] + }, + { + "key": "Elderly / Renal Impairment", + "val": "MANDATORY — Start at 2.5 mg **OD**. Highly susceptible to hypoglycemia.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Minidiab, Melizide", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 2 Diabetes Mellitus.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Alternative to Gliclazide. Useful in patients who experience post-prandial spikes but drop low overnight on longer-acting agents.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Type 1 Diabetes, Diabetic Ketoacidosis (DKA), severe hepatic or renal impairment.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. Avoid due to neonatal hypoglycemia.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation", "paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers mask the adrenergic warning signs of hypoglycemia (tremor/tachycardia).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Fluconazole/Miconazole inhibit CYP2C9, significantly increasing glipizide levels and hypo risk.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Regular **BSL** checks. Withhold if the patient is NBM (Nil By Mouth) for surgery or a scan.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **HbA1c** and **U&E**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 30-Minute Rule", + "val": "Unlike Gliclazide which can be taken *with* meals, Glipizide works best when taken 30 minutes *before* a meal, ensuring the forced insulin spike perfectly matches the post-prandial glucose spike.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to the SUR1 receptor on pancreatic beta cells, closing ATP-dependent K+ channels, depolarizing the cell, and forcing massive insulin exocytosis.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-4 hours. Extensively hepatically metabolised to inactive metabolites.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - MINIDIAB/glipizide ARTG, PI/CMI, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Sulfonylurea — Short-acting, second-generation sulfonylurea." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg). (Minidiab, Melizide)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 5 mg **OD** (30 mins before breakfast). Titrate by 2.5-5 mg every few days. Doses > 15 mg/day must be given **BD**. Max **40 mg/day** (Doses > 15 mg should be divided)." + }, + { + "label": "Key Indication Doses", + "value": "Type 2 Diabetes: Start **PO** 5 mg **OD** (30 mins before breakfast). Titrate by 2.5-5 mg every few days. Doses > 15 mg/day must be given **BD**. Elderly / Renal Impairment: Start at 2.5 mg **OD**. Highly susceptible to hypoglycemia." + }, + { + "label": "Best Uses", + "value": "Glipizide is a short-acting sulfonylurea for type 2 diabetes, but causes hypoglycaemia and weight gain and has largely been replaced by newer agents with better safety profiles." + }, + { + "label": "Avoid / Cautions", + "value": "Type 1 Diabetes, Diabetic Ketoacidosis (DKA), severe hepatic or renal impairment. **Pregnancy** Category C. Avoid due to neonatal hypoglycemia." + }, + { + "label": "Key Risks", + "value": "Endocrine: Severe hypoglycemia. HIGH — Weight gain (anabolic insulin effect). Gastrointestinal: Nausea, diarrhea. Immunological: Sulfa-allergy cross-reactivity." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers mask the adrenergic warning signs of hypoglycemia (tremor/tachycardia). Fluconazole/Miconazole inhibit CYP2C9, significantly increasing glipizide levels and hypo risk." + }, + { + "label": "Monitoring", + "value": "Regular **BSL** checks. Withhold if the patient is NBM (Nil By Mouth) for surgery or a scan. Routine **HbA1c** and **U&E**." + }, + { + "label": "Clinical Pearl", + "value": "Unlike Gliclazide which can be taken *with* meals, Glipizide works best when taken 30 minutes *before* a meal, ensuring the forced insulin spike perfectly matches the post-prandial glucose spike." + } + ] + }, + { + "slug": "linagliptin", + "name": "Linagliptin", + "class": "Antidiabetic", + "subclass": "DPP-4 Inhibitor", + "category": "Endocrinology - Oral Antidiabetics", + "accent": "#16a34a", + "tag": "ORAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "5 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12 h", + "cls": "", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "NOT REQ.", + "cls": "good", + "flag": "" + }, + { + "label": "Pancreatitis", + "value": "RARE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "DPP-4 Inhibitor (Gliptin). Blocks the breakdown of endogenous GLP-1. Unique among gliptins because it requires absolutely ZERO dose adjustment in renal failure.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **5 mg/day** (Flat dosing).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The absolute safest and most convenient oral antidiabetic for a patient with severe, fluctuating, or end-stage chronic kidney disease.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Linagliptin is the only DPP-4 inhibitor requiring no renal dose adjustment (hepatic elimination), but provides modest HbA1c reduction and lacks cardiovascular outcome benefits.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Acute pancreatitis (rare but severe). LOW — Nausea, diarrhea.", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "MODERATE — Severe, disabling arthralgia (joint pain) has been linked to the entire DPP-4 class. Resolves on cessation.", + "tags": [] + }, + { + "key": "Endocrine", + "val": "SAFE — Zero hypoglycemia risk when used as monotherapy. Weight neutral.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes", + "val": "**PO** 5 mg **OD** (with or without food).", + "tags": [] + }, + { + "key": "Renal / Hepatic Impairment", + "val": "SAFE — No dose adjustments required for any degree of renal or hepatic impairment.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Trajenta, Trajentamet (combo with metformin)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 2 Diabetes Mellitus.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The go-to add-on agent when Metformin fails or is contraindicated, specifically in patients with an eGFR < 30 where Sitagliptin would require complex dose reductions.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of pancreatitis. Type 1 Diabetes.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Linagliptin pregnancy row is Category B3/caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong CYP3A4/P-gp inducers (Rifampicin) significantly drop linagliptin blood levels, reducing efficacy.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Warn patient to report severe, radiating upper abdominal pain immediately (pancreatitis).", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **HbA1c**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Renal Exception", + "val": "Every other oral diabetes drug (Metformin, Gliclazide, Sitagliptin, Empagliflozin) either stops working or becomes highly toxic in severe renal failure. Linagliptin is the only oral drug you can safely give at full dose to a dialysis patient.", + "tags": [] + }, + { + "key": "The GLP-1 Clash", + "val": "Never prescribe Linagliptin to a patient already taking a GLP-1 agonist injection (like Ozempic). It provides zero additive benefit and wastes money.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits DPP-4, preventing the rapid degradation of incretin hormones (GLP-1 and GIP). This causes glucose-dependent insulin release and glucagon suppression.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1.5 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12 hours. Excreted >90% unchanged via the biliary/faecal route (bypasses kidneys).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TRAJENTA ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "DPP-4 Inhibitor — DPP-4 Inhibitor (Gliptin)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg). (Trajenta, Trajentamet (combo with metformin))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5 mg **OD** (with or without food). Max **5 mg/day** (Flat dosing)." + }, + { + "label": "Key Indication Doses", + "value": "Type 2 Diabetes: **PO** 5 mg **OD** (with or without food). Renal / Hepatic Impairment: No dose adjustments required for any degree of renal or hepatic impairment." + }, + { + "label": "Best Uses", + "value": "Linagliptin is the only DPP-4 inhibitor requiring no renal dose adjustment (hepatic elimination), but provides modest HbA1c reduction and lacks cardiovascular outcome benefits." + }, + { + "label": "Avoid / Cautions", + "value": "History of pancreatitis. Type 1 Diabetes. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Acute pancreatitis (rare but severe). LOW — Nausea, diarrhea. Musculoskeletal: Severe, disabling arthralgia (joint pain) has been linked to the entire DPP-4 class. Resolves on cessation. Endocrine: Zero hypoglycemia risk when used as monotherapy. Weight neutral." + }, + { + "label": "Key Interactions", + "value": "Strong CYP3A4/P-gp inducers (Rifampicin) significantly drop linagliptin blood levels, reducing efficacy." + }, + { + "label": "Monitoring", + "value": "Warn patient to report severe, radiating upper abdominal pain immediately (pancreatitis). Routine **HbA1c**." + }, + { + "label": "Clinical Pearl", + "value": "Every other oral diabetes drug (Metformin, Gliclazide, Sitagliptin, Empagliflozin) either stops working or becomes highly toxic in severe renal failure. Linagliptin is the only oral drug you can safely give at full dose to a dialysis patient." + } + ] + }, + { + "slug": "metformin", + "name": "Metformin", + "class": "Antidiabetic", + "subclass": "Biguanide", + "category": "Endocrinology - Oral Antidiabetics", + "accent": "#16a34a", + "tag": "ORAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "3 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6.5 h", + "cls": "", + "flag": "" + }, + { + "label": "Lactic Acidosis", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "eGFR < 30", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The absolute foundational first-line therapy for Type 2 Diabetes. Enhances insulin sensitivity and suppresses hepatic glucose output without causing weight gain.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **3 g/day** (though benefit plateaus at 2 g/day).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly toxic if accumulated. Must be withheld in acute kidney injury, severe hypoxia, or sepsis due to risk of fatal lactic acidosis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Metformin is the undisputed first-line oral hypoglycaemic for type 2 diabetes with cardiovascular benefit, but must be withheld before contrast and in acute kidney injury due to lactic acidosis risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Metformin-Associated Lactic Acidosis (MALA). High mortality rate. Occurs when drug accumulates (renal failure) or tissues are starved of oxygen (sepsis, heart failure).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, diarrhea, abdominal cramping (extremely common, affects up to 30%, usually transient).", + "tags": [] + }, + { + "key": "Haematological", + "val": "MODERATE — Vitamin B12 malabsorption with long-term use.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes (IR)", + "val": "**PO** 500 mg **OD** or **BD** with meals. Titrate slowly to 1000 mg **BD**.", + "tags": [] + }, + { + "key": "Type 2 Diabetes (XR)", + "val": "**PO** 500-2000 mg **OD** with the evening meal.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Max 1000 mg/day if **eGFR** 30-45. Cease entirely if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Diabex, Diaformin, Formet", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Immediate Release (IR) Tablets (500, 850, 1000 mg). Extended Release (XR) Tablets (500, 1000 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 2 Diabetes Mellitus.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "PCOS (improves ovulation), metabolic syndrome.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "First-line agent. Zero risk of hypoglycemia when used alone.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal impairment (**eGFR** < 30), severe tissue hypoxia (acute MI, acute decompensated heart failure, severe sepsis), acute severe liver disease.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Avoid metformin in severe renal impairment because of lactic-acidosis risk." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category C, but widely used and safe in gestational diabetes.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Metformin pregnancy row is framed as safe/widely used and should not trigger a contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — IV Contrast Dye. Contrast can cause acute kidney injury. If a patient on metformin gets contrast-induced AKI, the metformin will accumulate and cause fatal lactic acidosis. Withhold metformin for 48 hours post-contrast if eGFR is borderline.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Alcohol (increases risk of lactic acidosis).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and 6-monthly **eGFR**. Annual B12 levels. Routine **HbA1c**.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — 'Sick Day Rules': Instruct patients to withhold Metformin if they develop gastroenteritis (dehydration) to prevent acute renal failure and MALA.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The GI Fix", + "val": "If a patient cannot tolerate the explosive diarrhea from standard Metformin IR, switch them to the Extended Release (XR) version taken with dinner. It bypasses upper GI rapid absorption and cures the nausea/diarrhea in 90% of cases.", + "tags": [] + }, + { + "key": "The Fasting Myth", + "val": "Metformin does not stimulate insulin release. Therefore, it will NEVER cause a hypo on its own. You do not need to withhold it simply because a patient is fasting (unless they are NBM for surgery/contrast).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Decreases hepatic gluconeogenesis, decreases intestinal absorption of glucose, and improves peripheral insulin sensitivity (increases peripheral glucose uptake and utilization).", + "tags": [] + }, + { + "key": "Onset", + "val": "Days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "6.5 hours (Excreted entirely unchanged in the urine, no hepatic metabolism).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DIABEX ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Biguanide — The absolute foundational first-line therapy for Type 2 Diabetes." + }, + { + "label": "Route / Formulation", + "value": "Immediate Release (IR) Tablets (500, 850, 1000 mg). Extended Release (XR) Tablets (500, 1000 mg). (Diabex, Diaformin, Formet)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 500 mg **OD** or **BD** with meals. Titrate slowly to 1000 mg **BD**. Max **3 g/day** (though benefit plateaus at 2 g/day)." + }, + { + "label": "Key Indication Doses", + "value": "Type 2 Diabetes (IR): **PO** 500 mg **OD** or **BD** with meals. Titrate slowly to 1000 mg **BD**. Type 2 Diabetes (XR): **PO** 500-2000 mg **OD** with the evening meal. Renal Impairment: Max 1000 mg/day if **eGFR** 30-45. Cease entirely if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Metformin is the undisputed first-line oral hypoglycaemic for type 2 diabetes with cardiovascular benefit, but must be withheld before contrast and in acute kidney injury due to lactic acidosis risk." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal impairment (**eGFR** < 30), severe tissue hypoxia (acute MI, acute decompensated heart failure, severe sepsis), acute severe liver disease. **Pregnancy** Category C, but widely used and safe in gestational diabetes." + }, + { + "label": "Key Risks", + "value": "Metabolic: Metformin-Associated Lactic Acidosis (MALA). High mortality rate. Occurs when drug accumulates (renal failure) or tissues are starved of oxygen (sepsis, heart failure). Gastrointestinal: Nausea, diarrhea, abdominal cramping (extremely common, affects up to 30%, usually transient). Haematological: Vitamin B12 malabsorption with long-term use." + }, + { + "label": "Key Interactions", + "value": "IV Contrast Dye. Contrast can cause acute kidney injury. If a patient on metformin gets contrast-induced AKI, the metformin will accumulate and cause fatal lactic acidosis. Withhold metformin for 48 hours post-contrast if eGFR is borderline. Alcohol (increases risk of lactic acidosis)." + }, + { + "label": "Monitoring", + "value": "Baseline and 6-monthly **eGFR**. Annual B12 levels. Routine **HbA1c**. 'Sick Day Rules': Instruct patients to withhold Metformin if they develop gastroenteritis (dehydration) to prevent acute renal failure and MALA." + }, + { + "label": "Clinical Pearl", + "value": "If a patient cannot tolerate the explosive diarrhea from standard Metformin IR, switch them to the Extended Release (XR) version taken with dinner. It bypasses upper GI rapid absorption and cures the nausea/diarrhea in 90% of cases." + } + ] + }, + { + "slug": "sitagliptin", + "name": "Sitagliptin", + "class": "Antidiabetic", + "subclass": "DPP-4 Inhibitor", + "category": "Endocrinology - Oral Antidiabetics", + "accent": "#16a34a", + "tag": "ORAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "100 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12 h", + "cls": "", + "flag": "" + }, + { + "label": "Pancreatitis", + "value": "RARE", + "cls": "warn", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "DPP-4 Inhibitor (Gliptin). Prevents the breakdown of the body's natural incretin hormones (GLP-1), enhancing insulin release only when food is eaten. Extremely safe, weight-neutral, with zero hypo risk.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **100 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Requires strict dose reduction in renal impairment as it accumulates heavily.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Sitagliptin is a well-tolerated DPP-4 inhibitor for type 2 diabetes with weight neutrality, but provides modest HbA1c reduction and lacks the cardiovascular benefits of SGLT2i and GLP-1 agonists.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea. CRITICAL — Acute pancreatitis (rare but severe).", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "MODERATE — Severe, disabling joint pain (arthralgia) has been reported, reversing upon cessation.", + "tags": [] + }, + { + "key": "Immunological", + "val": "RARE — Bullous pemphigoid, hypersensitivity.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Type 2 Diabetes", + "val": "**PO** 100 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** 30-45, reduce to 50 mg **OD**. If **eGFR** < 30, reduce to 25 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Januvia, Janumet (combo with metformin)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (25 mg, 50 mg, 100 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Type 2 Diabetes Mellitus.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Excellent 'add-on' drug for elderly or frail patients where hypoglycemia (from sulfonylureas) must be avoided at all costs.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of pancreatitis, Type 1 Diabetes.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Sitagliptin pregnancy row is Category B3/caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "LOW — Extremely clean drug interaction profile. Highly safe to mix with most ward medications.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Check **eGFR** to guide correct dosing tier (100/50/25). Routine **HbA1c**.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Warn patient to report severe, radiating upper abdominal pain immediately (pancreatitis).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The GLP-1 Clash", + "val": "DPP-4 inhibitors work by saving the body's natural GLP-1. If a patient is already taking a synthetic GLP-1 agonist (like Ozempic or Trulicity), adding Sitagliptin provides absolutely zero extra benefit. They should never be prescribed together.", + "tags": [] + }, + { + "key": "The Hypo Safety", + "val": "Because incretins only stimulate insulin when food is in the gut, Sitagliptin is completely 'glucose-dependent'. It will never cause a hypo in a fasting patient.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits the Dipeptidyl Peptidase-4 (DPP-4) enzyme. This stops the destruction of GLP-1 and GIP. These hormones then stimulate glucose-dependent insulin release and suppress glucagon.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** Rapid.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12 hours. Cleared almost entirely unchanged by the kidneys.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - JANUVIA ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "DPP-4 Inhibitor — DPP-4 Inhibitor (Gliptin)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (25 mg, 50 mg, 100 mg). (Januvia, Janumet (combo with metformin))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 100 mg **OD**. Max **100 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Type 2 Diabetes: **PO** 100 mg **OD**. Renal Impairment: If **eGFR** 30-45, reduce to 50 mg **OD**. If **eGFR** < 30, reduce to 25 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Sitagliptin is a well-tolerated DPP-4 inhibitor for type 2 diabetes with weight neutrality, but provides modest HbA1c reduction and lacks the cardiovascular benefits of SGLT2i and GLP-1 agonists." + }, + { + "label": "Avoid / Cautions", + "value": "History of pancreatitis, Type 1 Diabetes. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea. CRITICAL — Acute pancreatitis (rare but severe). Musculoskeletal: Severe, disabling joint pain (arthralgia) has been reported, reversing upon cessation. Immunological: RARE — Bullous pemphigoid, hypersensitivity." + }, + { + "label": "Key Interactions", + "value": "Extremely clean drug interaction profile. Highly safe to mix with most ward medications." + }, + { + "label": "Monitoring", + "value": "Check **eGFR** to guide correct dosing tier (100/50/25). Routine **HbA1c**. Warn patient to report severe, radiating upper abdominal pain immediately (pancreatitis)." + }, + { + "label": "Clinical Pearl", + "value": "DPP-4 inhibitors work by saving the body's natural GLP-1. If a patient is already taking a synthetic GLP-1 agonist (like Ozempic or Trulicity), adding Sitagliptin provides absolutely zero extra benefit. They should never be prescribed together." + } + ] + }, + { + "slug": "dexamethasone", + "name": "Dexamethasone", + "class": "Steroid", + "subclass": "Glucocorticoid", + "category": "Endocrinology - Systemic Corticosteroids", + "accent": "#16a34a", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Variable", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "36-54 h", + "cls": "", + "flag": "" + }, + { + "label": "Mineralo. Effect", + "value": "ZERO", + "cls": "good", + "flag": "" + }, + { + "label": "Psychiatric SE", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-potent, long-acting synthetic glucocorticoid. 25-30 times more potent than Hydrocortisone. Brilliant brain penetration and absolute zero fluid-retaining (mineralocorticoid) activity.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max varies widely (e.g., 40 mg/day for myeloma, 4-8 mg for antiemetic).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The absolute drug of choice for cerebral oedema (brain tumors) and severe pediatric croup.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dexamethasone is the most potent long-acting corticosteroid for cerebral oedema, croup, and CINV prophylaxis, but even short courses cause significant hyperglycaemia and long-term use has devastating metabolic effects.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "HIGH — Extreme hyperglycemia (often requires insulin on the ward), Cushing's syndrome.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Steroid-induced psychosis, mania, severe insomnia, delirium.", + "tags": [] + }, + { + "key": "Immunological", + "val": "HIGH — Profound immunosuppression (risk of thrush, severe infections).", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "HIGH — Proximal myopathy (muscle wasting), avascular necrosis.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Cerebral Oedema (Tumor)", + "val": "**IV** / **PO** 4-16 mg/day in divided doses.", + "tags": [] + }, + { + "key": "Croup (Paediatric)", + "val": "**PO** 0.15 mg/kg STAT as a single dose (Max 12 mg).", + "tags": [] + }, + { + "key": "Chemotherapy Antiemetic", + "val": "**PO** / **IV** 4-8 mg given prior to chemo.", + "tags": [] + }, + { + "key": "COVID-19 (Severe)", + "val": "**PO** / **IV** 6 mg **OD** for 10 days.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dexmethsone, Decadron", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (0.5 mg, 4 mg). Oral liquid.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (4 mg/1 mL, 8 mg/2 mL) for **IV** / **IM**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Cerebral oedema, severe croup, multiple myeloma, severe COVID-19, antiemetic.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Reserved for when intense, long-lasting anti-inflammatory power is needed without ANY salt/water retention.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Systemic fungal infections, live vaccines.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category A/C. (Unlike Prednisolone, Dexamethasone actively crosses the placenta. Intentionally used to mature fetal lungs in premature labour, but avoid chronic use).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Dexamethasone pregnancy row is a benefit-risk caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — NSAIDs (Massive risk of bleeding gastric ulcers).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Strict **BSL** checks. Even non-diabetic patients can hit sugars of 20+ on high doses of Dex.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Give morning doses only (unless antiemetic) to prevent severe insomnia.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Brain Drain", + "val": "Hydrocortisone causes water retention. If you have a brain tumor, holding onto water increases brain swelling and kills you. Dexamethasone has zero water retention, aggressively shrinking the brain swelling instead. That is why it is the only steroid used in neurosurgery.", + "tags": [] + }, + { + "key": "The Perineal Burn", + "val": "If you push Dexamethasone rapidly IV in an awake patient, they will often experience an intense, excruciating burning/itching sensation in their perineum and genitals. It lasts 30 seconds and is harmless, but highly distressing. Push it slowly.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds exclusively to glucocorticoid receptors, profoundly suppressing inflammation. Because it has zero mineralocorticoid receptor affinity, it causes NO sodium or water retention in the kidneys.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** / **IV** 1-2 hours for full genomic effect.", + "tags": [] + }, + { + "key": "Duration", + "val": "Up to 72 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "36-54 hours (Biological tissue half-life).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DEXAMETHASONE VIATRIS ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Glucocorticoid — Ultra-potent, long-acting synthetic glucocorticoid." + }, + { + "label": "Route / Formulation", + "value": "Tablets (0.5 mg, 4 mg). Oral liquid. (Dexmethsone, Decadron)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** / **PO** 4-16 mg/day in divided doses. Max varies widely (e.g., 40 mg/day for myeloma, 4-8 mg for antiemetic)." + }, + { + "label": "Key Indication Doses", + "value": "Cerebral Oedema (Tumor): **IV** / **PO** 4-16 mg/day in divided doses. Croup (Paediatric): **PO** 0.15 mg/kg STAT as a single dose (Max 12 mg). Chemotherapy Antiemetic: **PO** / **IV** 4-8 mg given prior to chemo. COVID-19 (Severe): **PO** / **IV** 6 mg **OD** for 10 days." + }, + { + "label": "Best Uses", + "value": "Dexamethasone is the most potent long-acting corticosteroid for cerebral oedema, croup, and CINV prophylaxis, but even short courses cause significant hyperglycaemia and long-term use has devastating metabolic effects." + }, + { + "label": "Avoid / Cautions", + "value": "Systemic fungal infections, live vaccines. **Pregnancy** Category A/C. (Unlike Prednisolone, Dexamethasone actively crosses the placenta. Intentionally used to mature fetal lungs in premature labour, but avoid chronic use)." + }, + { + "label": "Key Risks", + "value": "Metabolic: Extreme hyperglycemia (often requires insulin on the ward), Cushing's syndrome. Neurological: Steroid-induced psychosis, mania, severe insomnia, delirium. Immunological: Profound immunosuppression (risk of thrush, severe infections). Musculoskeletal: Proximal myopathy (muscle wasting), avascular necrosis." + }, + { + "label": "Key Interactions", + "value": "NSAIDs (Massive risk of bleeding gastric ulcers)." + }, + { + "label": "Monitoring", + "value": "Strict **BSL** checks. Even non-diabetic patients can hit sugars of 20+ on high doses of Dex. Give morning doses only (unless antiemetic) to prevent severe insomnia." + }, + { + "label": "Clinical Pearl", + "value": "Hydrocortisone causes water retention. If you have a brain tumor, holding onto water increases brain swelling and kills you. Dexamethasone has zero water retention, aggressively shrinking the brain swelling instead. That is why it is the only steroid used in neurosurgery." + } + ] + }, + { + "slug": "fludrocortisone", + "name": "Fludrocortisone", + "class": "Steroid", + "subclass": "Mineralocorticoid", + "category": "Endocrinology - Systemic Corticosteroids", + "accent": "#16a34a", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "0.3 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "18-36 h", + "cls": "", + "flag": "" + }, + { + "label": "Hypokalemia", + "value": "CRITICAL RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Fluid Retention", + "value": "POTENT", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "A purely synthetic mineralocorticoid. Has virtually zero anti-inflammatory effect but is incredibly potent at retaining sodium and water. Acts as a synthetic aldosterone.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **0.3 mg/day** (Usually 0.1 mg/day).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Drastically dumps potassium into the urine. Hypokalemia is virtually guaranteed without monitoring or dietary adjustments.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Fludrocortisone is the only available mineralocorticoid for adrenal insufficiency and orthostatic hypotension, but causes sodium retention and hypokalaemia requiring electrolyte monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Severe hypokalemia (leading to fatal arrhythmias). HIGH — Fluid retention, severe edema, rapid weight gain, hypernatremia.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Severe hypertension, heart failure exacerbation (due to volume overload).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Addison's Disease (Primary Adrenal Failure)", + "val": "**PO** 0.05 - 0.1 mg **OD** (Given alongside Hydrocortisone).", + "tags": [] + }, + { + "key": "Postural Hypotension / Dysautonomia", + "val": "**PO** 0.1 - 0.2 mg **OD** (Off-label, used to expand blood volume).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Florinef", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (0.1 mg = 100 mcg). MUST be kept refrigerated.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Mineralocorticoid replacement in Addison's disease, salt-losing adrenogenital syndrome.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Severe refractory orthostatic hypotension, POTS.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Mandatory daily life-support drug for patients whose adrenal glands are destroyed (Addison's) and cannot make aldosterone.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Uncontrolled hypertension, congestive heart failure.", + "tags": [] + }, + { + "key": "Secondary Adrenal Failure", + "val": "CRITICAL — If a patient has adrenal failure due to pituitary disease (no ACTH), they DO NOT need Fludrocortisone. The RAAS system still makes aldosterone fine. They only need Hydrocortisone.", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Potassium-wasting diuretics (Frusemide, Thiazides) will cause catastrophic, synergistic hypokalemia.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Digoxin (Toxicity skyrockets due to the fludrocortisone-induced hypokalemia).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Strict, regular **U&E** monitoring (Potassium).", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Monitor **BP** and daily **Weight** to track fluid overload.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Fridge Rule", + "val": "Fludrocortisone is notoriously unstable at room temperature. It MUST be stored in the fridge. If a patient keeps it in their bathroom cabinet, the drug will degrade, their blood pressure will crash, and they will present in an Addisonian crisis.", + "tags": [] + }, + { + "key": "The Salt Craving", + "val": "Patients on adequate fludrocortisone replacement should not have intense salt cravings. If an Addison's patient is eating jars of pickles and drinking soy sauce, their fludrocortisone dose is too low.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to mineralocorticoid receptors in the distal convoluted tubule of the kidney. Forces the kidney to reabsorb massive amounts of sodium (and water) back into the blood, while forcing potassium and hydrogen out into the urine.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to reach steady-state fluid volume expansion.", + "tags": [] + }, + { + "key": "Half-life", + "val": "18-36 hours (Biological effect lasts 1-2 days).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - FLUDROCORTISONE MEDSURGE/MEDICIANZ ARTG, CMI, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Mineralocorticoid — A purely synthetic mineralocorticoid." + }, + { + "label": "Route / Formulation", + "value": "Tablets (0.1 mg = 100 mcg). MUST be kept refrigerated. (Florinef)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 0.05 - 0.1 mg **OD** (Given alongside Hydrocortisone). Max **0.3 mg/day** (Usually 0.1 mg/day)." + }, + { + "label": "Key Indication Doses", + "value": "Addison's Disease (Primary Adrenal Failure): **PO** 0.05 - 0.1 mg **OD** (Given alongside Hydrocortisone). Postural Hypotension / Dysautonomia: **PO** 0.1 - 0.2 mg **OD** (Off-label, used to expand blood volume)." + }, + { + "label": "Best Uses", + "value": "Fludrocortisone is the only available mineralocorticoid for adrenal insufficiency and orthostatic hypotension, but causes sodium retention and hypokalaemia requiring electrolyte monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Uncontrolled hypertension, congestive heart failure." + }, + { + "label": "Key Risks", + "value": "Metabolic: Severe hypokalemia (leading to fatal arrhythmias). HIGH — Fluid retention, severe edema, rapid weight gain, hypernatremia. Cardiovascular: Severe hypertension, heart failure exacerbation (due to volume overload)." + }, + { + "label": "Key Interactions", + "value": "Potassium-wasting diuretics (Frusemide, Thiazides) will cause catastrophic, synergistic hypokalemia. Digoxin (Toxicity skyrockets due to the fludrocortisone-induced hypokalemia)." + }, + { + "label": "Monitoring", + "value": "Strict, regular **U&E** monitoring (Potassium). Monitor **BP** and daily **Weight** to track fluid overload." + }, + { + "label": "Clinical Pearl", + "value": "Fludrocortisone is notoriously unstable at room temperature. It MUST be stored in the fridge. If a patient keeps it in their bathroom cabinet, the drug will degrade, their blood pressure will crash, and they will present in an Addisonian crisis." + } + ] + }, + { + "slug": "hydrocortisone", + "name": "Hydrocortisone", + "class": "Steroid", + "subclass": "Glucocorticoid", + "category": "Endocrinology - Systemic Corticosteroids", + "accent": "#16a34a", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg/day (Crisis)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1.5 h", + "cls": "", + "flag": "" + }, + { + "label": "Mineralo. Effect", + "value": "HIGH", + "cls": "warn", + "flag": "" + }, + { + "label": "Adrenal Crisis", + "value": "1ST LINE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Short-acting glucocorticoid. Synthetically identical to endogenous human cortisol. Contains equal parts glucocorticoid (anti-inflammatory) and mineralocorticoid (salt-retaining) activity.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mg/day** (Used IV during acute Addisonian crisis).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The absolute life-saving drug for acute adrenal insufficiency or severe refractory septic shock.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Hydrocortisone is a physiological corticosteroid for adrenal crisis, acute asthma, and inflammatory conditions, but requires stress dosing in adrenal insufficiency and long-term use causes adrenal suppression.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "HIGH — Hyperglycemia, hypernatremia, hypokalemia, fluid retention, weight gain.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Hypertension (due to mineralocorticoid fluid retention).", + "tags": [] + }, + { + "key": "Immunological", + "val": "HIGH — Immunosuppression, impaired wound healing.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Adrenal Crisis", + "val": "**IV** 100 mg STAT, followed by 50-100 mg q6h until stable.", + "tags": [] + }, + { + "key": "Refractory Septic Shock", + "val": "**IV** 200 mg/day (often as a continuous infusion or 50 mg q6h) to restore vascular tone.", + "tags": [] + }, + { + "key": "Replacement Therapy", + "val": "**PO** 10-20 mg in the morning, and 5-10 mg in the late afternoon (to mimic physiological cortisol rhythms).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Solu-Cortef (IV), Hysone (Oral)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (4 mg, 20 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (100 mg powder) for **IV** / **IM** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Adrenal insufficiency (Addison's disease), adrenal crisis, refractory shock, severe acute asthma (IV).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The physiological baseline. Replaces what the body cannot make during stress.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Systemic fungal infections (unless life-threatening adrenal crisis, where there are zero absolute contraindications).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. Hydrocortisone is heavily inactivated by placental enzymes, protecting the fetus from high doses.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Hydrocortisone pregnancy row is Category A/safe and should not trigger a contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Loop/Thiazide Diuretics (Synergistic hypokalemia). NSAIDs (GI bleeding).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — 'Sick Day Rules'. Patients on oral replacement MUST double or triple their oral dose if they get a fever, infection, or surgery. Failure to do so will result in a fatal adrenal crisis.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor **BSL** and **U&E** (potassium drops, sodium rises).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Mineralocorticoid Difference", + "val": "Unlike Dexamethasone (which is pure anti-inflammatory), Hydrocortisone strongly retains salt and water. This makes it vastly superior in septic shock, where you desperately need to fill the blood vessels with fluid to raise the BP.", + "tags": [] + }, + { + "key": "The Stress Dose", + "val": "The normal human makes ~20mg of cortisol a day. Under severe surgical stress or trauma, the body naturally makes up to 200-300mg. If your patient has no adrenals, you MUST provide this 300mg 'stress dose' via IV, or they will undergo cardiovascular collapse.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to intracellular glucocorticoid and mineralocorticoid receptors. Up-regulates anti-inflammatory proteins, down-regulates pro-inflammatory cytokines, and promotes sodium/water retention in the kidneys.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 1-2 hours for full genomic effect (though vascular stabilization occurs faster).", + "tags": [] + }, + { + "key": "Half-life", + "val": "1.5 hours (Short acting, must be dosed multiple times a day for replacement).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - HYDROCORTISONE JUNO ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Glucocorticoid — Short-acting glucocorticoid." + }, + { + "label": "Route / Formulation", + "value": "Tablets (4 mg, 20 mg). (Solu-Cortef (IV), Hysone (Oral))" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 100 mg STAT, followed by 50-100 mg q6h until stable. Max **400 mg/day** (Used IV during acute Addisonian crisis)." + }, + { + "label": "Key Indication Doses", + "value": "Acute Adrenal Crisis: **IV** 100 mg STAT, followed by 50-100 mg q6h until stable. Refractory Septic Shock: **IV** 200 mg/day (often as a continuous infusion or 50 mg q6h) to restore vascular tone. Replacement Therapy: **PO** 10-20 mg in the morning, and 5-10 mg in the late afternoon (to mimic physiological cortisol rhythms)." + }, + { + "label": "Best Uses", + "value": "Hydrocortisone is a physiological corticosteroid for adrenal crisis, acute asthma, and inflammatory conditions, but requires stress dosing in adrenal insufficiency and long-term use causes adrenal suppression." + }, + { + "label": "Avoid / Cautions", + "value": "Systemic fungal infections (unless life-threatening adrenal crisis, where there are zero absolute contraindications). **Pregnancy** Category A. Hydrocortisone is heavily inactivated by placental enzymes, protecting the fetus from high doses." + }, + { + "label": "Key Risks", + "value": "Metabolic: Hyperglycemia, hypernatremia, hypokalemia, fluid retention, weight gain. Cardiovascular: Hypertension (due to mineralocorticoid fluid retention). Immunological: Immunosuppression, impaired wound healing." + }, + { + "label": "Key Interactions", + "value": "Loop/Thiazide Diuretics (Synergistic hypokalemia). NSAIDs (GI bleeding)." + }, + { + "label": "Monitoring", + "value": "'Sick Day Rules'. Patients on oral replacement MUST double or triple their oral dose if they get a fever, infection, or surgery. Failure to do so will result in a fatal adrenal crisis. Monitor **BSL** and **U&E** (potassium drops, sodium rises)." + }, + { + "label": "Clinical Pearl", + "value": "Unlike Dexamethasone (which is pure anti-inflammatory), Hydrocortisone strongly retains salt and water. This makes it vastly superior in septic shock, where you desperately need to fill the blood vessels with fluid to raise the BP." + } + ] + }, + { + "slug": "methylprednisolone", + "name": "Methylprednisolone", + "class": "Steroid", + "subclass": "Glucocorticoid", + "category": "Endocrinology - Systemic Corticosteroids", + "accent": "#16a34a", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1 g/day (Pulse)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-3 h", + "cls": "", + "flag": "" + }, + { + "label": "Psychosis", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Anti-inflam", + "value": "POTENT", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent IV glucocorticoid. Has zero mineralocorticoid (salt-retaining) activity. Used for massive 'pulse' therapy to rapidly crush severe autoimmune flares.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1 g/day** (1000 mg) for 3-5 days strictly for pulse therapy.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Massive 1g IV doses frequently cause severe, acute steroid-induced psychosis and massive blood sugar spikes.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Methylprednisolone is a potent IV corticosteroid for acute MS relapses and severe inflammatory conditions, but high-dose pulse therapy carries cardiac arrhythmia risk and requires slow infusion.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Steroid psychosis, mania, severe insomnia, delirium. (Occurs in ~5-10% of patients receiving 1g pulses).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Extreme hyperglycemia (often requiring temporary insulin infusions even in non-diabetics).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Arrhythmias if infused too rapidly (Must infuse 1g over at least 60 mins).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "MS Flare / Optic Neuritis", + "val": "**IV** 1000 mg (1 g) **OD** infused over 1 hour, for 3 to 5 days.", + "tags": [] + }, + { + "key": "Severe Lupus / Vasculitis", + "val": "**IV** 500-1000 mg/day for 3 days.", + "tags": [] + }, + { + "key": "Spinal Cord Injury (Controversial)", + "val": "**IV** 30 mg/kg bolus followed by 5.4 mg/kg/hr (Specialist trauma only).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Solu-Medrol, Depo-Medrol (LA IM)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (40, 125, 500, 1000 mg powder) for **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital/Specialist supply.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute exacerbations of Multiple Sclerosis, severe SLE, optic neuritis, acute spinal cord injury.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "The ultimate 'nuke' for an autoimmune crisis. Avoids the lethal fluid overload that 1g of Hydrocortisone would cause.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Systemic fungal infections, active untreated tuberculosis.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category A, but high doses risk fetal growth restriction.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Methylprednisolone pregnancy row is Category A but framed as high-dose caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Macrolides (Clarithromycin) and Azoles inhibit CYP3A4, blocking methylprednisolone clearance and worsening toxicity.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Strict QID **BSL** monitoring. Inform the patient and family about the risk of acute mood changes or hallucinations.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor **U&E** (potassium can still drop despite low mineralocorticoid activity).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Rapid Taper Myth", + "val": "If you give a patient 1g of Methylprednisolone for 3 days, you do NOT need to taper them down. The HPA axis does not permanently suppress after only 3 days. You can stop the drug cold-turkey without causing an adrenal crisis.", + "tags": [] + }, + { + "key": "The Bitter Taste", + "val": "Patients often report an intense, horrible metallic/bitter taste in their mouth seconds after the IV infusion starts. This is harmless and transient. Giving them a mint to suck on helps.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds glucocorticoid receptors with 5x the potency of hydrocortisone. Massively downregulates inflammatory cytokines and leukocyte migration. Zero mineralocorticoid cross-reactivity.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours (Biological tissue effect lasts 12-36 hours).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DEPO-MEDROL/METHYLPRED ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Glucocorticoid — Highly potent IV glucocorticoid." + }, + { + "label": "Route / Formulation", + "value": "Vials (40, 125, 500, 1000 mg powder) for **IV** infusion. (Solu-Medrol, Depo-Medrol (LA IM))" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 1000 mg (1 g) **OD** infused over 1 hour, for 3 to 5 days. Max **1 g/day** (1000 mg) for 3-5 days strictly for pulse therapy." + }, + { + "label": "Key Indication Doses", + "value": "MS Flare / Optic Neuritis: **IV** 1000 mg (1 g) **OD** infused over 1 hour, for 3 to 5 days. Severe Lupus / Vasculitis: **IV** 500-1000 mg/day for 3 days. Spinal Cord Injury (Controversial): **IV** 30 mg/kg bolus followed by 5.4 mg/kg/hr (Specialist trauma only)." + }, + { + "label": "Best Uses", + "value": "Methylprednisolone is a potent IV corticosteroid for acute MS relapses and severe inflammatory conditions, but high-dose pulse therapy carries cardiac arrhythmia risk and requires slow infusion." + }, + { + "label": "Avoid / Cautions", + "value": "Systemic fungal infections, active untreated tuberculosis. **Pregnancy** Category A, but high doses risk fetal growth restriction." + }, + { + "label": "Key Risks", + "value": "Neurological: Steroid psychosis, mania, severe insomnia, delirium. (Occurs in ~5-10% of patients receiving 1g pulses). Metabolic: Extreme hyperglycemia (often requiring temporary insulin infusions even in non-diabetics). Cardiovascular: Arrhythmias if infused too rapidly (Must infuse 1g over at least 60 mins)." + }, + { + "label": "Key Interactions", + "value": "Macrolides (Clarithromycin) and Azoles inhibit CYP3A4, blocking methylprednisolone clearance and worsening toxicity." + }, + { + "label": "Monitoring", + "value": "Strict QID **BSL** monitoring. Inform the patient and family about the risk of acute mood changes or hallucinations. Monitor **U&E** (potassium can still drop despite low mineralocorticoid activity)." + }, + { + "label": "Clinical Pearl", + "value": "If you give a patient 1g of Methylprednisolone for 3 days, you do NOT need to taper them down. The HPA axis does not permanently suppress after only 3 days. You can stop the drug cold-turkey without causing an adrenal crisis." + } + ] + }, + { + "slug": "prednisolone", + "name": "Prednisolone", + "class": "Steroid", + "subclass": "Glucocorticoid", + "category": "Endocrinology - Systemic Corticosteroids", + "accent": "#16a34a", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "75 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-4 h", + "cls": "", + "flag": "" + }, + { + "label": "Hyperglycemia", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Tapering", + "value": "REQUIRED", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The quintessential oral systemic glucocorticoid. Provides profound, rapid suppression of the immune system and inflammatory cascades.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **75 mg/day** (Doses > 50 mg/day are generally considered massive and reserved for extreme rheumatologic/pulmonary flares).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Use > 2 weeks suppresses the HPA axis. Abrupt cessation will cause fatal Addisonian crisis. Must be tapered.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Prednisolone is the most commonly used oral corticosteroid for inflammatory, autoimmune, and allergic conditions, but long-term use causes devastating metabolic, bone, and adrenal suppression effects requiring slow taper.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — HPA axis suppression. HIGH — Severe hyperglycemia (especially post-prandial), Cushing's syndrome (moon face, buffalo hump, central obesity).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Steroid psychosis, delirium, severe insomnia, mania.", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "HIGH — Osteoporosis (with chronic use), avascular necrosis of the femoral head, steroid myopathy.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Peptic ulceration (especially combined with NSAIDs).", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Immunological", + "val": "HIGH — Profound immunosuppression (risk of thrush, severe bacterial/viral infections).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Asthma / COPD Flare", + "val": "**PO** 37.5 - 50 mg **OD** in the morning for 5 days. (No taper required for < 5 day courses).", + "tags": [] + }, + { + "key": "Rheumatoid Arthritis Flare", + "val": "**PO** 10-25 mg **OD**, tapering rapidly to lowest effective dose.", + "tags": [] + }, + { + "key": "Gout Flare", + "val": "**PO** 35 mg **OD** for 3-5 days (if NSAIDs/colchicine contraindicated).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Panafcortelone, Solone, Redipred (liquid)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (1 mg, 5 mg, 25 mg). Oral liquid (5 mg/mL). Take with food.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute asthma/COPD, rheumatoid arthritis, IBD flares, severe allergic reactions, giant cell arteritis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The most commonly prescribed oral steroid on the ward. Five times more potent anti-inflammatory action than hydrocortisone.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Systemic fungal infections, live vaccines (if on high doses).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category A, but chronic use risks fetal adrenal suppression and cleft palate.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Prednisolone pregnancy row is Category A but chronic-use caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — NSAIDs. Concurrent use massively amplifies the risk of bleeding gastric ulcers. Cover with a PPI.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Fluoroquinolones (Ciprofloxacin) exponentially increase the risk of Achilles tendon rupture.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — **BSL** checks. Even non-diabetic patients can hit sugars of 20+ on 50mg of prednisolone.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Baseline DEXA scan for bone density if anticipating > 3 months of use.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Morning Rule", + "val": "Always prescribe the entire daily dose in the morning (with breakfast). Giving it at night destroys the patient's sleep architecture and causes severe insomnia and mood disturbance.", + "tags": [] + }, + { + "key": "The 5-Day Free Pass", + "val": "If a course of Prednisolone is 5 days or shorter, the adrenal glands do not go to sleep. You can stop it abruptly on Day 5. No tapering is required.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Enters the cell nucleus, alters gene transcription, synthesizes lipocortin, and utterly shuts down the arachidonic acid inflammatory cascade (blocks phospholipase A2).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "18-36 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-4 hours (Biological tissue half-life is much longer).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - SOLONE prednisolone ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Glucocorticoid — The quintessential oral systemic glucocorticoid." + }, + { + "label": "Route / Formulation", + "value": "Tablets (1 mg, 5 mg, 25 mg). Oral liquid (5 mg/mL). Take with food. (Panafcortelone, Solone, Redipred (liquid))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 37.5 - 50 mg **OD** in the morning for 5 days. (No taper required for < 5 day courses). Max **75 mg/day** (Doses > 50 mg/day are generally considered massive and reserved for extreme rheumatologic/pulmonary flares)." + }, + { + "label": "Key Indication Doses", + "value": "Asthma / COPD Flare: **PO** 37.5 - 50 mg **OD** in the morning for 5 days. (No taper required for < 5 day courses). Rheumatoid Arthritis Flare: **PO** 10-25 mg **OD**, tapering rapidly to lowest effective dose. Gout Flare: **PO** 35 mg **OD** for 3-5 days (if NSAIDs/colchicine contraindicated)." + }, + { + "label": "Best Uses", + "value": "Prednisolone is the most commonly used oral corticosteroid for inflammatory, autoimmune, and allergic conditions, but long-term use causes devastating metabolic, bone, and adrenal suppression effects requiring slow taper." + }, + { + "label": "Avoid / Cautions", + "value": "Systemic fungal infections, live vaccines (if on high doses). **Pregnancy** Category A, but chronic use risks fetal adrenal suppression and cleft palate." + }, + { + "label": "Key Risks", + "value": "Endocrine: HPA axis suppression. HIGH — Severe hyperglycemia (especially post-prandial), Cushing's syndrome (moon face, buffalo hump, central obesity). Neurological: Steroid psychosis, delirium, severe insomnia, mania. Musculoskeletal: Osteoporosis (with chronic use), avascular necrosis of the femoral head, steroid myopathy. Gastrointestinal: Peptic ulceration (especially combined with NSAIDs)." + }, + { + "label": "Key Interactions", + "value": "NSAIDs. Concurrent use massively amplifies the risk of bleeding gastric ulcers. Cover with a PPI. Fluoroquinolones (Ciprofloxacin) exponentially increase the risk of Achilles tendon rupture." + }, + { + "label": "Monitoring", + "value": "**BSL** checks. Even non-diabetic patients can hit sugars of 20+ on 50mg of prednisolone. Baseline DEXA scan for bone density if anticipating > 3 months of use." + }, + { + "label": "Clinical Pearl", + "value": "Always prescribe the entire daily dose in the morning (with breakfast). Giving it at night destroys the patient's sleep architecture and causes severe insomnia and mood disturbance." + } + ] + }, + { + "slug": "prednisone", + "name": "Prednisone", + "class": "Steroid", + "subclass": "Glucocorticoid", + "category": "Endocrinology - Systemic Corticosteroids", + "accent": "#16a34a", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "75 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-3 h", + "cls": "", + "flag": "" + }, + { + "label": "Prodrug", + "value": "HEPATIC ACTIVATION", + "cls": "warn", + "flag": "" + }, + { + "label": "Hyperglycemia", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Oral systemic glucocorticoid. Biologically inactive prodrug that must be converted by the liver into the active drug, Prednisolone. Identical clinical use to Prednisolone.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **75 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Completely useless in severe liver failure, as the liver cannot convert it to the active form. Use Prednisolone instead in cirrhotic patients.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Prednisone is an oral corticosteroid prodrug (converted to prednisolone) for inflammatory and autoimmune conditions, but shares all the same long-term risks as prednisolone including adrenal suppression.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — HPA axis suppression if used > 2 weeks. HIGH — Severe hyperglycemia, Cushing's syndrome (moon face, central obesity).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Steroid psychosis, delirium, severe insomnia.", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "HIGH — Osteoporosis (with chronic use), avascular necrosis of the femoral head, steroid myopathy.", + "tags": [] + }, + { + "key": "Immunological", + "val": "HIGH — Profound immunosuppression (risk of thrush, severe infections).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Asthma / COPD Flare", + "val": "**PO** 40-50 mg **OD** in the morning for 5 days.", + "tags": [] + }, + { + "key": "Rheumatoid / Autoimmune Flare", + "val": "**PO** 10-25 mg **OD**, tapering rapidly to lowest effective dose.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "CRITICAL — Avoid. Must substitute with Prednisolone to bypass the broken hepatic conversion step.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Panafcort, Sone", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (1 mg, 5 mg, 25 mg). Take with food to prevent gastric ulceration.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute asthma/COPD, rheumatoid arthritis, IBD flares, severe allergic reactions, immunosuppression.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Widely prescribed globally (particularly in the US), though Australia frequently defaults directly to Prednisolone to eliminate the metabolic variable.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Systemic fungal infections, live vaccines (if on high doses). Severe hepatic failure.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category A, but chronic use risks fetal adrenal suppression.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Prednisone pregnancy row is Category A but chronic-use caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — NSAIDs. Concurrent use massively amplifies the risk of bleeding gastric ulcers. Cover with a PPI.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Fluoroquinolones (Ciprofloxacin) exponentially increase the risk of Achilles tendon rupture.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — **BSL** checks. Even non-diabetic patients can hit sugars of 20+ on 50mg of prednisone.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Take the full dose in the morning to prevent severe insomnia.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Conversion Ratio", + "val": "Prednisone and Prednisolone are mg-for-mg equivalent. 25mg of Prednisone = 25mg of Prednisolone. You can safely swap them 1:1 on the ward if stock of one runs out (provided the patient has a functioning liver).", + "tags": [] + }, + { + "key": "The 5-Day Free Pass", + "val": "If a course of Prednisone is 5 days or shorter, the adrenal glands do not go to sleep. You can stop it abruptly on Day 5. No tapering is required.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug. Converted by the enzyme 11-beta-hydroxysteroid dehydrogenase type 1 in the liver to active Prednisolone. Enters the cell nucleus and suppresses pro-inflammatory gene transcription.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours (Slightly slower than Prednisolone due to conversion step).", + "tags": [] + }, + { + "key": "Duration", + "val": "18-36 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours (Biological tissue half-life is much longer).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - predniSONE ARTG/AusPAR evidence and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Glucocorticoid — Oral systemic glucocorticoid." + }, + { + "label": "Route / Formulation", + "value": "Tablets (1 mg, 5 mg, 25 mg). Take with food to prevent gastric ulceration. (Panafcort, Sone)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 40-50 mg **OD** in the morning for 5 days. Max **75 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Asthma / COPD Flare: **PO** 40-50 mg **OD** in the morning for 5 days. Rheumatoid / Autoimmune Flare: **PO** 10-25 mg **OD**, tapering rapidly to lowest effective dose. Hepatic Impairment: Avoid. Must substitute with Prednisolone to bypass the broken hepatic conversion step." + }, + { + "label": "Best Uses", + "value": "Prednisone is an oral corticosteroid prodrug (converted to prednisolone) for inflammatory and autoimmune conditions, but shares all the same long-term risks as prednisolone including adrenal suppression." + }, + { + "label": "Avoid / Cautions", + "value": "Systemic fungal infections, live vaccines (if on high doses). Severe hepatic failure. **Pregnancy** Category A, but chronic use risks fetal adrenal suppression." + }, + { + "label": "Key Risks", + "value": "Endocrine: HPA axis suppression if used > 2 weeks. HIGH — Severe hyperglycemia, Cushing's syndrome (moon face, central obesity). Neurological: Steroid psychosis, delirium, severe insomnia. Musculoskeletal: Osteoporosis (with chronic use), avascular necrosis of the femoral head, steroid myopathy. Immunological: Profound immunosuppression (risk of thrush, severe infections)." + }, + { + "label": "Key Interactions", + "value": "NSAIDs. Concurrent use massively amplifies the risk of bleeding gastric ulcers. Cover with a PPI. Fluoroquinolones (Ciprofloxacin) exponentially increase the risk of Achilles tendon rupture." + }, + { + "label": "Monitoring", + "value": "**BSL** checks. Even non-diabetic patients can hit sugars of 20+ on 50mg of prednisone. Take the full dose in the morning to prevent severe insomnia." + }, + { + "label": "Clinical Pearl", + "value": "Prednisone and Prednisolone are mg-for-mg equivalent. 25mg of Prednisone = 25mg of Prednisolone. You can safely swap them 1:1 on the ward if stock of one runs out (provided the patient has a functioning liver)." + } + ] + }, + { + "slug": "alendronate", + "name": "Alendronate", + "class": "Bone Metabolism", + "subclass": "Bisphosphonate", + "category": "Endocrinology - Thyroid & Bone", + "accent": "#16a34a", + "tag": "BISPHOSPHONATE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "70 mg/week", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10 YEARS", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Esophagitis", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + }, + { + "label": "Empty Stomach", + "value": "MANDATORY", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent antiresorptive nitrogenous bisphosphonate. The first-line oral therapy for osteoporosis. Binds permanently to bone to prevent osteoclast destruction.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **70 mg/week** (Osteoporosis) or **40 mg/day** (Paget's disease).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Has < 1% oral bioavailability. Must be taken exactly as prescribed (fasting, upright, water only) or it will completely fail to absorb and ulcerate the esophagus.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Alendronate is the first-line oral bisphosphonate for osteoporosis prevention and treatment, but must be taken upright with water on an empty stomach and carries risk of oesophageal ulceration and rare osteonecrosis of the jaw.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Severe erosive esophagitis, esophageal ulcers, strictures.", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "HIGH — Osteonecrosis of the jaw (ONJ), atypical femoral fractures (associated with use > 5 years).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hypocalcemia (transient, usually asymptomatic).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Osteoporosis (Treatment/Prophylaxis)", + "val": "**PO** 70 mg ONCE WEEKLY.", + "tags": [] + }, + { + "key": "Glucocorticoid-Induced Osteoporosis", + "val": "**PO** 70 mg ONCE WEEKLY.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Not recommended if **CrCl** < 35 mL/min.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "crcl": { + "lt": 35 + } + }, + "note": "Alendronate is not recommended when creatinine clearance is below 35 mL/min." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Fosamax, Fosamax Plus (combo with Colecalciferol)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg, 70 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Postmenopausal osteoporosis, male osteoporosis, glucocorticoid-induced osteoporosis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line agent. Proven to significantly reduce vertebral and non-vertebral fracture risk.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Oesophageal disorders delaying emptying, inability to stand/sit upright for at least 30 minutes, hypocalcaemia, or hypersensitivity.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3; avoid unless specialist benefit-risk review supports use.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Alendronate pregnancy exposure should prompt specialist benefit-risk review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Calcium supplements, antacids, food, coffee, juice. ANY multivalent cation will bind the drug in the gut, dropping absorption to zero. Must separate by at least 2 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Must be taken first thing in the morning, on an empty stomach, with a full glass of plain tap water. Patient MUST remain fully upright for 30 minutes.", + "tags": [] + }, + { + "key": "Imaging / Consults", + "val": "MANDATORY — Dental check-up required prior to initiation due to ONJ risk. Routine DEXA scans every 1-2 years.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Drug Holiday", + "val": "Because it remains in the bone for a decade, patients who have been on Alendronate for 5 years (or 3 years if high-risk) should have a 'drug holiday' to prevent the bone from becoming brittle and suffering an atypical femoral fracture.", + "tags": [] + }, + { + "key": "The Calcium Prerequisite", + "val": "Never start a bisphosphonate in a patient with Vitamin D deficiency or hypocalcemia. The drug will drive calcium into the bone, causing a severe hypocalcemic crash. Treat the deficiency first.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to hydroxyapatite crystals in bone. Ingested by osteoclasts during bone resorption. Inhibits the farnesyl pyrophosphate synthase enzyme, causing osteoclast apoptosis.", + "tags": [] + }, + { + "key": "Onset", + "val": "Bone density improvements seen at 3-6 months.", + "tags": [] + }, + { + "key": "Half-life", + "val": "> 10 YEARS (Permanently incorporated into the bone matrix). Renally cleared from plasma.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ALENDRONATE SANDOZ/FOSAMAX alendronate Australian CMI/PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Bisphosphonate — Potent antiresorptive nitrogenous bisphosphonate." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg, 70 mg). (Fosamax, Fosamax Plus (combo with Colecalciferol))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 70 mg ONCE WEEKLY. Max **70 mg/week** (Osteoporosis) or **40 mg/day** (Paget's disease)." + }, + { + "label": "Key Indication Doses", + "value": "Osteoporosis (Treatment/Prophylaxis): **PO** 70 mg ONCE WEEKLY. Glucocorticoid-Induced Osteoporosis: **PO** 70 mg ONCE WEEKLY. Renal Impairment: Avoid entirely if **eGFR** < 35 (risk of severe accumulation)." + }, + { + "label": "Best Uses", + "value": "Alendronate is the first-line oral bisphosphonate for osteoporosis prevention and treatment, but must be taken upright with water on an empty stomach and carries risk of oesophageal ulceration and rare osteonecrosis of the jaw." + }, + { + "label": "Avoid / Cautions", + "value": "Inability to stand/sit upright for 30 minutes. Esophageal stricture/achalasia. Hypocalcemia. **Pregnancy** Category B3. Incorporates into bone and could theoretically leach out during future pregnancies, affecting fetal skeleton." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe erosive esophagitis, esophageal ulcers, strictures. Musculoskeletal: Osteonecrosis of the jaw (ONJ), atypical femoral fractures (associated with use > 5 years). Metabolic: Hypocalcemia (transient, usually asymptomatic)." + }, + { + "label": "Key Interactions", + "value": "Calcium supplements, antacids, food, coffee, juice. ANY multivalent cation will bind the drug in the gut, dropping absorption to zero. Must separate by at least 2 hours." + }, + { + "label": "Monitoring", + "value": "Must be taken first thing in the morning, on an empty stomach, with a full glass of plain tap water. Patient MUST remain fully upright for 30 minutes. Dental check-up required prior to initiation due to ONJ risk. Routine DEXA scans every 1-2 years." + }, + { + "label": "Clinical Pearl", + "value": "Because it remains in the bone for a decade, patients who have been on Alendronate for 5 years (or 3 years if high-risk) should have a 'drug holiday' to prevent the bone from becoming brittle and suffering an atypical femoral fracture." + } + ] + }, + { + "slug": "carbimazole", + "name": "Carbimazole", + "class": "Thyroid", + "subclass": "Antithyroid Agent", + "category": "Endocrinology - Thyroid & Bone", + "accent": "#16a34a", + "tag": "THYROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "60 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6 h", + "cls": "", + "flag": "" + }, + { + "label": "Neutropenia", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Rash", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Thionamide antithyroid drug. The first-line medical therapy for Graves' disease and hyperthyroidism. Suppresses thyroid hormone synthesis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **60 mg/day** (During severe acute thyrotoxicosis). Maintenance is typically 5-15 mg/day.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Carries a rare but life-threatening risk of agranulocytosis. Patients must present to ED immediately if they develop a sore throat or fever.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Carbimazole is the first-line antithyroid drug for Graves' disease and thyrotoxicosis, but carries rare risk of fatal agranulocytosis requiring urgent FBC if sore throat/fever develops.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Agranulocytosis (absolute neutrophil count < 0.5). Occurs in 0.5% of patients, usually within the first 3 months.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "MODERATE — Cholestatic jaundice (less common than with PTU, but still a risk).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Dermatological", + "val": "HIGH — Pruritic maculopapular rash (occurs in ~5% of patients, often transient).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hyperthyroidism (Initiation)", + "val": "**PO** 15-40 mg/day (given as a single dose or divided **BD**).", + "tags": [] + }, + { + "key": "Maintenance Therapy", + "val": "**PO** 5-15 mg **OD**. Titrated strictly based on **TFTs** every 4-6 weeks.", + "tags": [] + }, + { + "key": "Block and Replace Regimen", + "val": "**PO** 40 mg **OD** (to completely shut down the thyroid), co-administered with Levothyroxine 50-150 mcg **OD** to maintain euthyroidism.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Neo-Mercazole", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hyperthyroidism, preparation for thyroidectomy or radioiodine therapy.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line for Graves' disease. Preferred over propylthiouracil (PTU) due to lower risk of severe hepatotoxicity.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Previous carbimazole/thiamazole agranulocytosis, serious blood disorder, acute pancreatitis after carbimazole/thiamazole, or severe hepatic impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Carbimazole is contraindicated/avoided in severe hepatic impairment or prior serious carbimazole toxicity." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C. Avoid if possible in the 1st trimester; if required, use the lowest effective dose with specialist review.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Carbimazole in pregnancy requires specialist review, especially in the first trimester." + } + }, + { + "key": "Lactation", + "val": "CAUTION — Use only with specialist advice; monitor infant thyroid function if breastfeeding continues.", + "tags": [], + "patient": { + "factors": ["lactation"], + "action": "monitor", + "severity": "caution", + "note": "Carbimazole during breastfeeding requires specialist advice and infant thyroid monitoring." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — As hyperthyroidism resolves, the clearance of other drugs (like Warfarin or Digoxin) slows down, massively increasing their toxicity if their doses aren't reduced accordingly.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Routine **TFTs** (TSH, Free T4, Free T3). **FBC** if patient reports any signs of infection. Baseline **LFTs**.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Counsel patient: 'If you get a sore throat, mouth ulcers, or fever, stop the medication and go to the Emergency Department for a blood test immediately.'", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The TSH Lag", + "val": "When treating hyperthyroidism, the Free T4 and Free T3 will normalize weeks before the TSH rises. Dose adjustments should initially be based on Free T4/T3, not TSH, to avoid over-treating and causing hypothyroidism.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug converted to methimazole. Inhibits thyroid peroxidase, blocking the oxidation of iodine and the coupling of iodotyrosines, halting the synthesis of T3 and T4.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks (Does not destroy existing circulating thyroid hormone, only prevents new synthesis).", + "tags": [] + }, + { + "key": "Half-life", + "val": "6 hours (but accumulates in the thyroid gland, allowing **OD** dosing).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: NEO-MERCAZOLE/carbimazole Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Antithyroid Agent — Thionamide antithyroid drug." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg). (Neo-Mercazole)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 15-40 mg/day (given as a single dose or divided **BD**). Max **60 mg/day** (During severe acute thyrotoxicosis). Maintenance is typically 5-15 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Hyperthyroidism (Initiation): **PO** 15-40 mg/day (given as a single dose or divided **BD**). Maintenance Therapy: **PO** 5-15 mg **OD**. Titrated strictly based on **TFTs** every 4-6 weeks. Block and Replace Regimen: **PO** 40 mg **OD** (to completely shut down the thyroid), co-administered with Levothyroxine 50-150 mcg **OD** to maintain euthyroidism." + }, + { + "label": "Best Uses", + "value": "Carbimazole is the first-line antithyroid drug for Graves' disease and thyrotoxicosis, but carries rare risk of fatal agranulocytosis requiring urgent FBC if sore throat/fever develops." + }, + { + "label": "Avoid / Cautions", + "value": "History of carbimazole-induced agranulocytosis or severe liver injury. **Pregnancy** Category C. PTU is generally preferred in the 1st trimester (due to rare carbimazole-associated embryopathy), but carbimazole is often used in 2nd/3rd trimesters." + }, + { + "label": "Key Risks", + "value": "Haematological: Agranulocytosis (absolute neutrophil count < 0.5). Occurs in 0.5% of patients, usually within the first 3 months. Hepatic: Cholestatic jaundice (less common than with PTU, but still a risk). Dermatological: Pruritic maculopapular rash (occurs in ~5% of patients, often transient)." + }, + { + "label": "Key Interactions", + "value": "As hyperthyroidism resolves, the clearance of other drugs (like Warfarin or Digoxin) slows down, massively increasing their toxicity if their doses aren't reduced accordingly." + }, + { + "label": "Monitoring", + "value": "Routine **TFTs** (TSH, Free T4, Free T3). **FBC** if patient reports any signs of infection. Baseline **LFTs**. Counsel patient: 'If you get a sore throat, mouth ulcers, or fever, stop the medication and go to the Emergency Department for a blood test immediately.'" + }, + { + "label": "Clinical Pearl", + "value": "When treating hyperthyroidism, the Free T4 and Free T3 will normalize weeks before the TSH rises. Dose adjustments should initially be based on Free T4/T3, not TSH, to avoid over-treating and causing hypothyroidism." + } + ] + }, + { + "slug": "denosumab", + "name": "Denosumab", + "class": "Bone Metabolism", + "subclass": "RANKL Inhibitor", + "category": "Endocrinology - Thyroid & Bone", + "accent": "#16a34a", + "tag": "BIOLOGIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "60 mg Q6M", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "26 Days", + "cls": "", + "flag": "" + }, + { + "label": "Hypocalcemia", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "NO ADJ; Ca RISK", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent monoclonal antibody against RANK Ligand. Extremely effective at halting bone resorption. Safe to use in severe renal failure (unlike bisphosphonates).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **60 mg every 6 months** (for osteoporosis). Oncology doses (Xgeva) are 120 mg every 4 weeks.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Do not delay or stop denosumab without transition planning: Australian warnings highlight multiple vertebral fracture risk after discontinuation or delayed doses.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Denosumab is a potent anti-resorptive monoclonal antibody for osteoporosis, but discontinuation causes rapid rebound bone loss with vertebral fracture risk, mandating transition to a bisphosphonate.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Severe symptomatic hypocalcemia (tetany, QTc prolongation, seizures), particularly in severe renal impairment.", + "tags": [], + "patient": { + "factors": ["renal", "qtc"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 15 + }, + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Musculoskeletal", + "val": "HIGH — Osteonecrosis of the jaw (ONJ), atypical femoral fractures. CRITICAL — Rebound vertebral fractures upon cessation.", + "tags": [] + }, + { + "key": "Immunological", + "val": "MODERATE — Increased risk of skin infections (cellulitis).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Osteoporosis", + "val": "**SC** 60 mg as a single injection EVERY 6 MONTHS. Must be co-administered with adequate calcium/Vit D supplementation.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CAUTION — No dose adjustment required, but severe renal impairment/dialysis greatly increases hypocalcaemia risk; correct calcium/vitamin D and monitor calcium closely.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "monitor", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Denosumab needs close calcium monitoring in severe renal impairment/dialysis because hypocalcaemia risk is increased." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Prolia (60 mg), Xgeva (120 mg - Oncology)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled syringe (60 mg/1 mL) for **SC** injection. Must be refrigerated.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Osteoporosis (especially if bisphosphonates are contraindicated/failed).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Prevention of skeletal related events in bone metastases (Xgeva).", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Second-line for osteoporosis, or first-line in severe CKD (eGFR < 35).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Pre-existing hypocalcemia. Unhealed dental/jaw lesions.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Immunosuppressants (additive risk of severe infections).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **U&E** and Calcium/Vit D/Magnesium within 1-2 weeks of injection. Correct any deficiency BEFORE giving the injection.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Ensure the patient is booked in precisely for their 6-month follow-up injection.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Rebound Trap", + "val": "Unlike bisphosphonates, Denosumab does NOT stay in the bone. When it washes out at 6 months, osteoclasts flood back. If you stop Denosumab, you MUST immediately start a bisphosphonate to lock the bone, otherwise the patient will suffer catastrophic spinal fractures within months.", + "tags": [] + }, + { + "key": "The CKD Paradox", + "val": "It is safe to clear in CKD, but patients with CKD have impaired calcium homeostasis. Giving Denosumab to a dialysis patient can cause a fatal hypocalcemic crash. Monitor intensely.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Human IgG2 monoclonal antibody that binds to RANKL, preventing it from activating RANK on the surface of osteoclasts. This prevents osteoclast formation, function, and survival.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** Rapid. Massive drop in bone resorption markers within days.", + "tags": [] + }, + { + "key": "Duration", + "val": "Exactly 6 months. Effect wears off rapidly thereafter.", + "tags": [] + }, + { + "key": "Half-life", + "val": "26 Days (Cleared via the reticuloendothelial system, not the kidneys).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: PROLIA/denosumab Australian PI, CMI, and TGA/Australian Prescriber warning source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "RANKL Inhibitor — Highly potent monoclonal antibody against RANK Ligand." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled syringe (60 mg/1 mL) for **SC** injection. Must be refrigerated. (Prolia (60 mg), Xgeva (120 mg - Oncology))" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** 60 mg as a single injection EVERY 6 MONTHS. Must be co-administered with adequate calcium/Vit D supplementation. Max **60 mg every 6 months** (for osteoporosis). Oncology doses (Xgeva) are 120 mg every 4 weeks." + }, + { + "label": "Key Indication Doses", + "value": "Osteoporosis: **SC** 60 mg as a single injection EVERY 6 MONTHS. Must be co-administered with adequate calcium/Vit D supplementation. Renal Impairment: No dose adjustment required in CKD or dialysis, but extreme vigilance required for hypocalcemia." + }, + { + "label": "Best Uses", + "value": "Denosumab is a potent anti-resorptive monoclonal antibody for osteoporosis, but discontinuation causes rapid rebound bone loss with vertebral fracture risk, mandating transition to a bisphosphonate." + }, + { + "label": "Avoid / Cautions", + "value": "Pre-existing hypocalcemia. Unhealed dental/jaw lesions. **Pregnancy** Category D." + }, + { + "label": "Key Risks", + "value": "Metabolic: Severe symptomatic hypocalcemia (tetany, QTc prolongation, seizures), particularly in severe renal impairment. Musculoskeletal: Osteonecrosis of the jaw (ONJ), atypical femoral fractures. CRITICAL — Rebound vertebral fractures upon cessation. Immunological: Increased risk of skin infections (cellulitis)." + }, + { + "label": "Key Interactions", + "value": "Immunosuppressants (additive risk of severe infections)." + }, + { + "label": "Monitoring", + "value": "Check **U&E** and Calcium/Vit D/Magnesium within 1-2 weeks of injection. Correct any deficiency BEFORE giving the injection. Ensure the patient is booked in precisely for their 6-month follow-up injection." + }, + { + "label": "Clinical Pearl", + "value": "Unlike bisphosphonates, Denosumab does NOT stay in the bone. When it washes out at 6 months, osteoclasts flood back. If you stop Denosumab, you MUST immediately start a bisphosphonate to lock the bone, otherwise the patient will suffer catastrophic spinal fractures within months." + } + ] + }, + { + "slug": "levothyroxine", + "name": "Levothyroxine", + "class": "Thyroid", + "subclass": "Thyroid Hormone Replacement", + "category": "Endocrinology - Thyroid & Bone", + "accent": "#16a34a", + "tag": "THYROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "200 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "7 DAYS", + "cls": "warn", + "flag": "" + }, + { + "label": "Empty Stomach", + "value": "MANDATORY", + "cls": "good", + "flag": "" + }, + { + "label": "Arrhythmia", + "value": "TOXICITY", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Synthetic thyroxine (T4). The gold standard replacement hormone for hypothyroidism. Narrow therapeutic index.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated strictly via TSH levels. Usually 50-200 mcg/day.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Absorption is highly erratic. Must be taken strictly on an empty stomach with water only.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Levothyroxine is the standard thyroid hormone replacement for hypothyroidism, but has extensive drug and food interactions (take fasting) and requires careful dose titration with regular TSH monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Iatrogenic hyperthyroidism (overdose) causes AF, tachycardia, angina, and myocardial infarction.", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "HIGH — Chronic mild over-replacement suppresses TSH and accelerates bone resorption, causing severe osteoporosis over decades.", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Tremor, anxiety, insomnia (signs of overdose).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypothyroidism (Young/Healthy)", + "val": "**PO** 1.6 mcg/kg **OD** (typically 100-150 mcg).", + "tags": [] + }, + { + "key": "Elderly / Ischemic Heart Disease", + "val": "MANDATORY — Start at **PO** 12.5 - 25 mcg **OD**. Titrate up glacially (every 4-6 weeks) to prevent acute myocardial infarction.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Oroxine, Eutroxsig, Eltroxin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (50 mcg, 75 mcg, 100 mcg, 200 mcg). Storage is brand-specific: Oroxine/Eutroxsig require refrigeration; Eltroxin storage differs.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Primary hypothyroidism, Hashimoto's thyroiditis, post-thyroidectomy.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Lifelong mandatory therapy for absent/failing thyroid gland.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Uncorrected adrenal insufficiency (Addison's). Starting T4 will hyper-accelerate metabolism and precipitate a fatal Addisonian crisis. Treat the adrenals first.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. Continue treatment and check TSH promptly; dose requirements commonly increase in pregnancy.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "monitor", + "severity": "info", + "note": "Levothyroxine usually continues in pregnancy; TSH should be checked and dose requirements often increase." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Calcium, iron, antacids, bile-acid sequestrants, and some foods/drinks can markedly reduce absorption. Separate interacting doses and keep administration consistent.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Monitor **TSH** every 6 weeks during titration. Do NOT check levels 3 days after a dose change; it takes 6 weeks for the HPA axis to stabilize.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Check **HR** for tachyarrhythmias.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Fasting Rule", + "val": "If a patient says their dose 'keeps having to be changed', they are taking it with coffee or breakfast. Counsel them to take it immediately upon waking, with water only, and wait 30-60 mins before eating or drinking coffee.", + "tags": [] + }, + { + "key": "The Brand Trap", + "val": "Oroxine and Eutroxsig are highly temperature sensitive and must be stored in the fridge. If left out in summer, they degrade rapidly, leading to hypothyroid relapses.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Synthetic T4. Enters cells and is converted to active T3 (triiodothyronine) by deiodinases. Binds to nuclear receptors to regulate systemic metabolic rate, cardiac function, and growth.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Full steady state takes 4-6 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "7 Days (Allows for highly stable blood levels despite occasional missed doses).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: OROXINE/levothyroxine Australian PI/CMI and healthdirect source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Thyroid Hormone Replacement — Synthetic thyroxine (T4)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (50 mcg, 75 mcg, 100 mcg, 200 mcg). MUST be kept refrigerated in WA Health (unless Eltroxin brand). (Oroxine, Eutroxsig, Eltroxin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1.6 mcg/kg **OD** (typically 100-150 mcg). Titrated strictly via TSH levels. Usually 50-200 mcg/day." + }, + { + "label": "Key Indication Doses", + "value": "Hypothyroidism (Young/Healthy): **PO** 1.6 mcg/kg **OD** (typically 100-150 mcg). Elderly / Ischemic Heart Disease: Start at **PO** 12.5 - 25 mcg **OD**. Titrate up glacially (every 4-6 weeks) to prevent acute myocardial infarction." + }, + { + "label": "Best Uses", + "value": "Levothyroxine is the standard thyroid hormone replacement for hypothyroidism, but has extensive drug and food interactions (take fasting) and requires careful dose titration with regular TSH monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Uncorrected adrenal insufficiency (Addison's). Starting T4 will hyper-accelerate metabolism and precipitate a fatal Addisonian crisis. Treat the adrenals first. **Pregnancy** Category A. Demands are HIGH in pregnancy. Dose must often be increased by 30-50% the moment pregnancy is confirmed to ensure fetal brain development." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Iatrogenic hyperthyroidism (overdose) causes AF, tachycardia, angina, and myocardial infarction. Musculoskeletal: Chronic mild over-replacement suppresses TSH and accelerates bone resorption, causing severe osteoporosis over decades. Neurological: Tremor, anxiety, insomnia (signs of overdose)." + }, + { + "label": "Key Interactions", + "value": "Calcium, Iron, Antacids, and Coffee bind thyroxine in the gut, completely destroying absorption. Must be separated by at least 4 hours." + }, + { + "label": "Monitoring", + "value": "Monitor **TSH** every 6 weeks during titration. Do NOT check levels 3 days after a dose change; it takes 6 weeks for the HPA axis to stabilize. Check **HR** for tachyarrhythmias." + }, + { + "label": "Clinical Pearl", + "value": "If a patient says their dose 'keeps having to be changed', they are taking it with coffee or breakfast. Counsel them to take it immediately upon waking, with water only, and wait 30-60 mins before eating or drinking coffee." + } + ] + }, + { + "slug": "risedronate", + "name": "Risedronate", + "class": "Bone Metabolism", + "subclass": "Bisphosphonate", + "category": "Endocrinology - Thyroid & Bone", + "accent": "#16a34a", + "tag": "BISPHOSPHONATE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "150 mg/month", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10 YEARS", + "cls": "", + "flag": "" + }, + { + "label": "Esophagitis", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Food Safe", + "value": "EC TABLET ONLY", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent oral bisphosphonate for osteoporosis. Highly similar to Alendronate. Incorporates permanently into bone to halt osteoclast destruction.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **150 mg ONCE MONTHLY** or **35 mg ONCE WEEKLY**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Standard tablets must be taken fasting and upright. However, the unique 'Enteric Coated' (EC) formulation MUST be taken WITH food.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Risedronate is an oral bisphosphonate for osteoporosis with weekly or monthly dosing, but requires the same strict upright fasting administration as alendronate to prevent oesophageal injury.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Severe erosive esophagitis, esophageal ulcers (with standard tablets).", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "HIGH — Osteonecrosis of the jaw (ONJ), atypical femoral fractures (with use > 5 years).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hypocalcemia (transient).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Osteoporosis (Standard Tablet)", + "val": "**PO** 35 mg ONCE WEEKLY. Must be taken 30 mins before breakfast, upright, with a full glass of tap water.", + "tags": [] + }, + { + "key": "Osteoporosis (EC Tablet)", + "val": "**PO** 35 mg ONCE WEEKLY. MUST be taken WITH or immediately after breakfast (requires food to trigger delayed release in the bowel).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Not recommended if **CrCl** < 30 mL/min.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "crcl": { + "lt": 30 + } + }, + "note": "Risedronate is not recommended when creatinine clearance is below 30 mL/min." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Actonel, Actonel EC", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Standard Tablets (35 mg, 150 mg). Enteric-Coated (EC) Tablets (35 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Postmenopausal and male osteoporosis, glucocorticoid-induced osteoporosis, Paget's disease.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line oral option. The EC formulation drastically improves compliance for patients who cannot tolerate the strict fasting rules of Alendronate.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Inability to stand/sit upright for 30 minutes. Esophageal stricture. Hypocalcemia.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3; avoid unless specialist benefit-risk review supports use.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Risedronate pregnancy exposure should prompt specialist benefit-risk review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Calcium supplements, antacids, dairy. Forms an indestructible physical complex in the gut, dropping absorption to zero. Separate by 2 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Double-check the box! Is it standard Actonel (must be empty stomach) or Actonel EC (must be taken with food)? Mixing this up guarantees clinical failure or esophageal burns.", + "tags": [] + }, + { + "key": "Imaging / Consults", + "val": "MANDATORY — Dental check-up required prior to initiation due to ONJ risk.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The EC Advantage", + "val": "Many elderly patients quit bisphosphonates because they hate waiting 30 minutes to eat breakfast or drink coffee. Switching them to Actonel EC (Enteric Coated) completely solves this, as it is designed to bypass the stomach and only release in the alkaline small intestine.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to hydroxyapatite crystals in bone. Ingested by osteoclasts during resorption, inhibiting farnesyl pyrophosphate synthase and causing osteoclast apoptosis.", + "tags": [] + }, + { + "key": "Onset", + "val": "Bone density improvements seen at 3-6 months.", + "tags": [] + }, + { + "key": "Half-life", + "val": "> 10 YEARS (Permanently incorporated into the bone matrix).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ACTONEL/risedronate Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Bisphosphonate — Potent oral bisphosphonate for osteoporosis." + }, + { + "label": "Route / Formulation", + "value": "Standard Tablets (35 mg, 150 mg). Enteric-Coated (EC) Tablets (35 mg). (Actonel, Actonel EC)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 35 mg ONCE WEEKLY. Must be taken 30 mins before breakfast, upright, with a full glass of tap water. Max **150 mg ONCE MONTHLY** or **35 mg ONCE WEEKLY**." + }, + { + "label": "Key Indication Doses", + "value": "Osteoporosis (Standard Tablet): **PO** 35 mg ONCE WEEKLY. Must be taken 30 mins before breakfast, upright, with a full glass of tap water. Osteoporosis (EC Tablet): **PO** 35 mg ONCE WEEKLY. MUST be taken WITH or immediately after breakfast (requires food to trigger delayed release in the bowel). Renal Impairment: Avoid entirely if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Risedronate is an oral bisphosphonate for osteoporosis with weekly or monthly dosing, but requires the same strict upright fasting administration as alendronate to prevent oesophageal injury." + }, + { + "label": "Avoid / Cautions", + "value": "Inability to stand/sit upright for 30 minutes. Esophageal stricture. Hypocalcemia. **Pregnancy** Category B3. Incorporates into bone and leaches out during future pregnancies." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe erosive esophagitis, esophageal ulcers (with standard tablets). Musculoskeletal: Osteonecrosis of the jaw (ONJ), atypical femoral fractures (with use > 5 years). Metabolic: Hypocalcemia (transient)." + }, + { + "label": "Key Interactions", + "value": "Calcium supplements, antacids, dairy. Forms an indestructible physical complex in the gut, dropping absorption to zero. Separate by 2 hours." + }, + { + "label": "Monitoring", + "value": "Double-check the box! Is it standard Actonel (must be empty stomach) or Actonel EC (must be taken with food)? Mixing this up guarantees clinical failure or esophageal burns. Dental check-up required prior to initiation due to ONJ risk." + }, + { + "label": "Clinical Pearl", + "value": "Many elderly patients quit bisphosphonates because they hate waiting 30 minutes to eat breakfast or drink coffee. Switching them to Actonel EC (Enteric Coated) completely solves this, as it is designed to bypass the stomach and only release in the alkaline small intestine." + } + ] + }, + { + "slug": "zoledronic-acid", + "name": "Zoledronic acid", + "class": "Bone Metabolism", + "subclass": "Bisphosphonate IV", + "category": "Endocrinology - Thyroid & Bone", + "accent": "#16a34a", + "tag": "BISPHOSPHONATE IV", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "5 mg/year", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10 YEARS", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Flu-Like", + "value": "1ST DOSE SEVERE", + "cls": "warn", + "flag": "" + }, + { + "label": "Hypocalcemia", + "value": "CRITICAL RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-potent, intravenous bisphosphonate. A single 15-minute infusion provides a full year of osteoporosis protection. Completely bypasses the severe GI side effects of oral bisphosphonates.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **5 mg ONCE YEARLY** (Osteoporosis) or **4 mg q3-4 weeks** (Oncology/Bone Mets).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The patient MUST have normal Vitamin D and Calcium levels before the infusion, or it will trigger a lethal hypocalcemic crash.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Zoledronic acid is a once-yearly IV bisphosphonate for osteoporosis providing maximum adherence, but causes acute-phase reaction (flu-like symptoms) after first infusion and requires adequate renal function.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Immunological", + "val": "CRITICAL — 'Acute Phase Reaction'. Within 24-48 hours of the *first* infusion, up to 50% of patients develop a severe flu-like syndrome (high fever, bone pain, rigors). It is harmless but terrifying. Prevent with Paracetamol.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "CRITICAL — Severe, symptomatic hypocalcemia (tetany/seizures) if given to a Vitamin D deficient patient.", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "HIGH — Osteonecrosis of the jaw (ONJ) - risk is much higher with IV formulations than oral.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Osteoporosis", + "val": "**IV** 5 mg infused strictly over no less than 15 minutes, ONCE YEARLY.", + "tags": [] + }, + { + "key": "Hypercalcemia of Malignancy", + "val": "**IV** 4 mg STAT.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Do not use Aclasta for osteoporosis if **CrCl** < 35 mL/min; check renal function before each infusion and ensure hydration.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "crcl": { + "lt": 35 + } + }, + "note": "Zoledronic acid for osteoporosis is contraindicated/not recommended when creatinine clearance is below 35 mL/min." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Aclasta (5 mg - Osteo), Zometa (4 mg - Oncology)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (4 mg/5 mL, 5 mg/100 mL) for **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Administered in hospital or infusion clinics.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Osteoporosis, Paget's disease, Hypercalcemia of malignancy, prevention of skeletal-related events in bone metastases.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The definitive option for patients who cannot tolerate oral bisphosphonates due to reflux/esophagitis, or those who are non-compliant.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Hypocalcaemia, severe renal impairment (**CrCl** < 35 mL/min for Aclasta osteoporosis use), pregnancy, or breastfeeding.", + "tags": [], + "patient": { + "factors": ["renal", "pregnancy", "lactation"], + "action": "contraindication", + "severity": "danger", + "match": { + "crcl": { + "lt": 35 + } + }, + "note": "Zoledronic acid is contraindicated in pregnancy/breastfeeding and in severe renal impairment for Aclasta osteoporosis use." + } + }, + { + "key": "Pregnancy", + "val": "CONTRAINDICATED — Do not use during pregnancy or breastfeeding.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "contraindication", + "severity": "danger", + "note": "Zoledronic acid is contraindicated during pregnancy and breastfeeding." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Loop diuretics and Aminoglycosides massively compound the risk of nephrotoxicity and hypocalcemia.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — You MUST hold a recent blood test proving normal Calcium, Vitamin D, and **eGFR** in your hand before authorizing the infusion.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Ensure the patient drinks 2 glasses of water before the infusion to protect the kidneys.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The One-Hit Wonder", + "val": "A single 15-minute infusion of 5mg Zoledronic Acid reduces the risk of spinal fractures by 70% over the next 3 years. It is an incredibly powerful, low-compliance-burden therapy.", + "tags": [] + }, + { + "key": "The Panadol Pre-Load", + "val": "To blunt the horrific 'Acute Phase Reaction', always pre-medicate the patient with 1g of Paracetamol 30 minutes before the infusion, and instruct them to take it regularly for the next 48 hours.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Intravenous administration floods the bone remodeling sites. Engulfed by osteoclasts, irreversibly shutting down their resorptive capability.", + "tags": [] + }, + { + "key": "Onset", + "val": "Maximal inhibition of bone resorption occurs within 1 week.", + "tags": [] + }, + { + "key": "Half-life", + "val": "> 10 YEARS (Locked in the bone matrix).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ACLASTA/ZOMETA zoledronic acid Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Bisphosphonate IV — Ultra-potent, intravenous bisphosphonate." + }, + { + "label": "Route / Formulation", + "value": "Vials (4 mg/5 mL, 5 mg/100 mL) for **IV** infusion. (Aclasta (5 mg - Osteo), Zometa (4 mg - Oncology))" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 5 mg infused strictly over no less than 15 minutes, ONCE YEARLY. Max **5 mg ONCE YEARLY** (Osteoporosis) or **4 mg q3-4 weeks** (Oncology/Bone Mets)." + }, + { + "label": "Key Indication Doses", + "value": "Osteoporosis: **IV** 5 mg infused strictly over no less than 15 minutes, ONCE YEARLY. Hypercalcemia of Malignancy: **IV** 4 mg STAT. Renal Impairment: Do not use if **eGFR** < 35. Rapid infusion causes acute renal failure. Ensure patient is highly hydrated." + }, + { + "label": "Best Uses", + "value": "Zoledronic acid is a once-yearly IV bisphosphonate for osteoporosis providing maximum adherence, but causes acute-phase reaction (flu-like symptoms) after first infusion and requires adequate renal function." + }, + { + "label": "Avoid / Cautions", + "value": "Hypocalcemia, severe renal impairment (**eGFR** < 35). **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Immunological: 'Acute Phase Reaction'. Within 24-48 hours of the *first* infusion, up to 50% of patients develop a severe flu-like syndrome (high fever, bone pain, rigors). It is harmless but terrifying. Prevent with Paracetamol. Metabolic: Severe, symptomatic hypocalcemia (tetany/seizures) if given to a Vitamin D deficient patient. Musculoskeletal: Osteonecrosis of the jaw (ONJ) - risk is much higher with IV formulations than oral." + }, + { + "label": "Key Interactions", + "value": "Loop diuretics and Aminoglycosides massively compound the risk of nephrotoxicity and hypocalcemia." + }, + { + "label": "Monitoring", + "value": "You MUST hold a recent blood test proving normal Calcium, Vitamin D, and **eGFR** in your hand before authorizing the infusion. Ensure the patient drinks 2 glasses of water before the infusion to protect the kidneys." + }, + { + "label": "Clinical Pearl", + "value": "A single 15-minute infusion of 5mg Zoledronic Acid reduces the risk of spinal fractures by 70% over the next 3 years. It is an incredibly powerful, low-compliance-burden therapy." + } + ] + }, + { + "slug": "ethinylestradiol", + "name": "Ethinylestradiol", + "class": "Hormone", + "subclass": "Estrogen", + "category": "Endocrinology - Women's Health", + "accent": "#16a34a", + "tag": "HORMONE", + "schedule": "S4", + "stats": [ + { + "label": "Dose", + "value": "20-35 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10-27 h", + "cls": "", + "flag": "" + }, + { + "label": "VTE Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Migraine Aura", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent synthetic estrogen. The primary estrogenic component of almost all Combined Oral Contraceptive Pills (COCPs). Suppresses ovulation and stabilizes the endometrium.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **50 mcg/day** (Modern COCPs use 20-35 mcg).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Combined hormonal contraception increases venous and arterial thrombotic risk; screen for aura migraine, smoking age >35, hypertension, VTE history, breast cancer, severe liver disease, and immobilisation risk before prescribing.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ethinylestradiol is the standard oestrogen component in combined oral contraceptives, but significantly increases VTE risk especially in smokers over 35 and with obesity or immobility.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Venous Thromboembolism (DVT/PE), arterial thrombosis (Stroke, MI), severe hypertension.", + "tags": [] + }, + { + "key": "Oncology", + "val": "MODERATE — Slight increase in breast/cervical cancer risk; significant DECREASE in ovarian/endometrial cancer risk.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea (estrogen-driven, worse with 35mcg pills).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Fluid retention, worsened migraines, melasma (skin darkening).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Contraception / Dysmenorrhoea", + "val": "**PO** 20-35 mcg **OD** (Combined with a progestin, taken for 21 days followed by 7 days of sugar pills or skipped for continuous active use).", + "tags": [] + }, + { + "key": "Missed Dose Rule", + "val": "MANDATORY — If a pill is < 24h late, take immediately. If > 24h late, take the most recent missed pill, discard older missed pills, and use backup barrier contraception for 7 days.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Levlen, Microgynon, Yaz, Yasmin, Brenda (All in combination with various progestins).", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (typically 20, 30, or 35 micrograms).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Contraception, severe dysmenorrhoea, heavy menstrual bleeding, acne, endometriosis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The most widely used reversible contraceptive. Non-contraceptive benefits (acne, bleeding control) drive massive prescribing.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Current/past VTE or arterial thromboembolism, migraine with aura, smoking age >35, severe/uncontrolled hypertension, breast cancer or suspected sex-steroid dependent malignancy, active/severe liver disease, and major surgery with prolonged immobilisation.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Existing absolute row names active/severe liver disease; severe hepatic impairment is the modeled patient-panel match." + } + }, + { + "key": "Pregnancy", + "val": "CONTRAINDICATED — Do not use if pregnant or pregnancy is suspected. Combined hormonal contraception can reduce breast milk supply; avoid early breastfeeding/postpartum use unless specifically advised.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "contraindication", + "severity": "danger", + "note": "Combined hormonal contraception is not indicated in pregnancy and needs postpartum/lactation review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Enzyme inducers such as carbamazepine, phenytoin, rifampicin/rifabutin, some antiretrovirals, and St John's wort can reduce contraceptive efficacy; use a non-interacting method or additional contraception per guidance.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Ethinylestradiol can lower lamotrigine concentrations during active tablets and levels may rebound during hormone-free intervals; coordinate dosing and monitoring if used together.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Check **BP** before prescribing and annually. Counsel on the symptoms of a DVT/PE (calf pain, sudden shortness of breath, chest pain).", + "tags": [] + }, + { + "key": "Surgery", + "val": "MANDATORY — Stop combined hormonal contraception before major surgery or any surgery expected to cause prolonged immobilisation; restart only when fully mobile and VTE risk is acceptable.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Aura Stroke Trap", + "val": "If a woman says she gets migraines with 'flashing lights or zig-zags' (aura), prescribing the COCP is medical negligence. The estrogen increases her baseline risk of an ischemic stroke by up to 600%. Use a Progestin-Only pill instead.", + "tags": [] + }, + { + "key": "Continuous Dosing", + "val": "The 7-day sugar pill break is a historical artifact designed to mimic a 'natural' period. There is zero medical reason to bleed every month. Counsel women that they can safely skip the sugar pills and take active pills continuously to avoid periods entirely.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Provides negative feedback to the hypothalamus and pituitary, suppressing the mid-cycle LH surge, completely halting ovulation.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days (Requires 7 days of continuous use to guarantee ovulation suppression).", + "tags": [] + }, + { + "key": "Half-life", + "val": "10-27 hours. Extensively metabolised by CYP3A4. Undergoes heavy enterohepatic recirculation.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: LEVLEN ED combined oral contraceptive Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Estrogen — Highly potent synthetic estrogen." + }, + { + "label": "Route / Formulation", + "value": "Tablets (typically 20, 30, or 35 micrograms). (Levlen, Microgynon, Yaz, Yasmin, Brenda (All in combination with various progestins).)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 20-35 mcg **OD** (Combined with a progestin, taken for 21 days followed by 7 days of sugar pills or skipped for continuous active use). Max **50 mcg/day** (Modern COCPs use 20-35 mcg)." + }, + { + "label": "Key Indication Doses", + "value": "Contraception / Dysmenorrhoea: **PO** 20-35 mcg **OD** (Combined with a progestin, taken for 21 days followed by 7 days of sugar pills or skipped for continuous active use). Missed Dose Rule: If a pill is < 24h late, take immediately. If > 24h late, take the most recent missed pill, discard older missed pills, and use backup barrier contraception for 7 days." + }, + { + "label": "Best Uses", + "value": "Ethinylestradiol is the standard oestrogen component in combined oral contraceptives, but significantly increases VTE risk especially in smokers over 35 and with obesity or immobility." + }, + { + "label": "Avoid / Cautions", + "value": "Current/past VTE or arterial thrombosis, migraine with aura, smoking age >35, severe/uncontrolled hypertension, breast cancer or suspected sex-steroid malignancy, active/severe liver disease, pregnancy, and major surgery/prolonged immobilisation. Combined hormonal contraception can reduce breast milk supply." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Venous Thromboembolism (DVT/PE), arterial thrombosis (Stroke, MI), severe hypertension. Oncology: Slight increase in breast/cervical cancer risk; significant DECREASE in ovarian/endometrial cancer risk. Gastrointestinal: Nausea (estrogen-driven, worse with 35mcg pills). Metabolic: Fluid retention, worsened migraines, melasma (skin darkening)." + }, + { + "label": "Key Interactions", + "value": "Hepatic Enzyme Inducers (Carbamazepine, Phenytoin, Rifampicin, St John's Wort). These completely shred the estrogen in the liver, causing the COCP to fail and leading to unintended pregnancy. Must use alternate contraception (Mirena/Copper IUD). Lamotrigine. Estrogen halves lamotrigine levels. When the patient takes their 7-day sugar pill break, lamotrigine levels double, causing acute neurotoxicity." + }, + { + "label": "Monitoring", + "value": "Check **BP** before prescribing and annually. Counsel on the symptoms of a DVT/PE (calf pain, sudden shortness of breath, chest pain). Must be ceased 4 WEEKS prior to major elective surgery to allow clotting factors to normalize and prevent post-op PE." + }, + { + "label": "Clinical Pearl", + "value": "If a woman says she gets migraines with 'flashing lights or zig-zags' (aura), prescribing the COCP is medical negligence. The estrogen increases her baseline risk of an ischemic stroke by up to 600%. Use a Progestin-Only pill instead." + } + ] + }, + { + "slug": "levonorgestrel", + "name": "Levonorgestrel", + "class": "Hormone", + "subclass": "Progestin", + "category": "Endocrinology - Women's Health", + "accent": "#16a34a", + "tag": "HORMONE", + "schedule": "S4", + "stats": [ + { + "label": "Emergency Dose", + "value": "1.5 mg STAT", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "24 h", + "cls": "", + "flag": "" + }, + { + "label": "BMI > 70kg", + "value": "DOUBLE DOSE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "VTE Risk", + "value": "SAFE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent, highly stable synthetic progestogen. Used as the 'Morning After Pill', the active hormone in the Mirena IUD, and the 'Mini-Pill'. Thickens cervical mucus and halts ovulation.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1.5 mg** STAT (Emergency Contraception) or **3 mg** STAT (if BMI > 26 or taking enzyme inducers).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Extremely safe regarding cardiovascular/clotting risk. The emergency contraceptive pill must be taken within 72 hours of unprotected intercourse.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Levonorgestrel is used in progestogen-only pills, IUDs, and emergency contraception, but the emergency dose must be taken within 72 hours and efficacy decreases significantly with delay.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea/Vomiting (Common with the massive 1.5mg emergency dose. If the patient vomits within 2 hours, they MUST take another dose).", + "tags": [] + }, + { + "key": "Gynecological", + "val": "HIGH — Irregular, unpredictable spotting/bleeding (especially in the first 3-6 months of Mirena or Mini-pill use).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "SAFE — Unlike estrogen, levonorgestrel does NOT increase the risk of DVT, PE, or stroke.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Emergency Contraception", + "val": "**PO** 1.5 mg STAT (Take ASAP, up to 72 hours post-intercourse).", + "tags": [] + }, + { + "key": "Heavy BMI (>70kg / BMI >26)", + "val": "CAUTION — Higher body weight/BMI and enzyme inducers may reduce oral emergency contraception efficacy. Discuss copper IUD or ulipristal where appropriate; if levonorgestrel is used with enzyme inducers, double-dose advice may apply under current guidance.", + "tags": [] + }, + { + "key": "Progestogen-Only Pill (Mini-Pill)", + "val": "**PO** 30 mcg **OD** (Must be taken at the EXACT same time every day. If > 3 hours late, effectiveness drops to zero).", + "tags": [] + }, + { + "key": "Intrauterine Device (IUD)", + "val": "Mirena (52 mg) releases 20 mcg/day continuously for 5 years directly into the uterus.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Postinor-1, Levonelle (Emergency). Microlut (Mini-Pill). Mirena (IUD).", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (1.5 mg, 30 mcg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Emergency Contraception is Over The Counter (S3). IUD/Mini-Pill is S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Emergency contraception, continuous contraception, heavy menstrual bleeding (Mirena).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The Mirena IUD is the absolute gold standard for treating heavy/painful periods and providing highly reliable, 'forget-proof' contraception.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Undiagnosed abnormal vaginal bleeding, active breast cancer, severe liver disease.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Existing absolute row names severe liver disease; severe hepatic impairment is the modeled patient-panel match." + } + }, + { + "key": "Pregnancy", + "val": "CONTRAINDICATED — Do not use emergency or maintenance levonorgestrel if pregnancy is known or suspected; accidental exposure is not evidence for pregnancy termination but needs review.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Levonorgestrel contraception is not indicated once pregnancy is known or suspected." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Enzyme inducers can reduce oral levonorgestrel exposure and emergency contraception efficacy; copper IUD is most reliable, or use current double-dose advice if oral levonorgestrel is chosen.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn patients taking the 30mcg Mini-Pill that they have a strict 3-hour window. Taking it at 8 AM one day and 12 PM the next means they are completely unprotected.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Ovulation Trap", + "val": "Levonorgestrel emergency contraception works by delaying ovulation. If the woman has *already* ovulated this cycle before having unprotected sex, the pill will 100% fail. Ulipristal (EllaOne) or a Copper IUD are better options if ovulation is imminent.", + "tags": [] + }, + { + "key": "The Breastfeeding Choice", + "val": "Because it contains zero estrogen, Levonorgestrel (Mini-Pill or Mirena) is perfectly safe to use immediately postpartum and does not suppress breast milk production.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Emergency: Delays or completely inhibits the LH surge, preventing ovulation. It does NOT abort an implanted embryo. Maintenance: Thickens cervical mucus to act as a physical barrier to sperm and thins the endometrium.", + "tags": [] + }, + { + "key": "Onset", + "val": "Rapid.", + "tags": [] + }, + { + "key": "Half-life", + "val": "24 hours. Metabolised by CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: POSTINOR-1, MICROLUT, and MIRENA levonorgestrel Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Progestin — Potent, highly stable synthetic progestogen." + }, + { + "label": "Route / Formulation", + "value": "Tablets (1.5 mg, 30 mcg). (Postinor-1, Levonelle (Emergency). Microlut (Mini-Pill). Mirena (IUD).)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1.5 mg STAT (Take ASAP, up to 72 hours post-intercourse). Max **1.5 mg** STAT (Emergency Contraception) or **3 mg** STAT (if BMI > 26 or taking enzyme inducers)." + }, + { + "label": "Key Indication Doses", + "value": "Emergency Contraception: **PO** 1.5 mg STAT (Take ASAP, up to 72 hours post-intercourse). Heavy BMI (>70kg / BMI >26): **PO** 3 mg STAT (Take two 1.5mg tablets together). The standard dose fails in heavier patients. Progestogen-Only Pill (Mini-Pill): **PO** 30 mcg **OD** (Must be taken at the EXACT same time every day. If > 3 hours late, effectiveness drops to zero). Intrauterine Device (IUD): Mirena (52 mg) releases 20 mcg/day continuously for 5 years directly into the uterus." + }, + { + "label": "Best Uses", + "value": "Levonorgestrel is used in progestogen-only pills, IUDs, and emergency contraception, but the emergency dose must be taken within 72 hours and efficacy decreases significantly with delay." + }, + { + "label": "Avoid / Cautions", + "value": "Known/suspected pregnancy, active breast cancer, severe liver disease or liver tumours, and unexplained vaginal bleeding need review before use. For emergency contraception, efficacy falls with delay, higher body weight, and enzyme-inducing medicines." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea/Vomiting (Common with the massive 1.5mg emergency dose. If the patient vomits within 2 hours, they MUST take another dose). Gynecological: Irregular, unpredictable spotting/bleeding (especially in the first 3-6 months of Mirena or Mini-pill use). Cardiovascular: Unlike estrogen, levonorgestrel does NOT increase the risk of DVT, PE, or stroke." + }, + { + "label": "Key Interactions", + "value": "Enzyme Inducers (Carbamazepine, Phenytoin, Rifampicin, St John's Wort). Destroy blood levels of oral levonorgestrel. If a patient on Epilepsy meds needs the Morning After Pill, you MUST double the dose to 3 mg STAT, or use a Copper IUD." + }, + { + "label": "Monitoring", + "value": "Warn patients taking the 30mcg Mini-Pill that they have a strict 3-hour window. Taking it at 8 AM one day and 12 PM the next means they are completely unprotected. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Levonorgestrel emergency contraception works by delaying ovulation. If the woman has *already* ovulated this cycle before having unprotected sex, the pill will 100% fail. Ulipristal (EllaOne) or a Copper IUD are better options if ovulation is imminent." + } + ] + }, + { + "slug": "medroxyprogesterone", + "name": "Medroxyprogesterone", + "class": "Hormone", + "subclass": "Progestin", + "category": "Endocrinology - Women's Health", + "accent": "#16a34a", + "tag": "HORMONE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "150 mg/12W (IM)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "50 DAYS (IM)", + "cls": "", + "flag": "" + }, + { + "label": "Bone Loss", + "value": "BLACK BOX", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Weight Gain", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent synthetic progestin. Most famously used as a 3-monthly contraceptive injection (Depo-Provera). Also used orally for menstrual regulation and endometriosis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **150 mg every 12 weeks** (**IM**).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Depot medroxyprogesterone can reduce bone mineral density; reassess long-term use, especially in adolescents or osteoporosis risk. Delayed return to fertility is common after stopping.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Medroxyprogesterone is a progestogen used for contraception (depot injection) and HRT, but the depot form causes significant bone density loss and delayed return of fertility.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Musculoskeletal", + "val": "CRITICAL — Bone mineral density can decrease during depot use, especially with longer duration. Reassess fracture risk and ongoing need, particularly in adolescents or osteoporosis risk.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Significant weight gain (average 2-3 kg/year), fluid retention.", + "tags": [] + }, + { + "key": "Gynecological", + "val": "HIGH — Irregular, unpredictable spotting/bleeding for the first 3-6 months. Delayed return to fertility (up to 18 months).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Contraception (Depo)", + "val": "**IM** 150 mg deep gluteal injection EVERY 12 WEEKS. (Must be given within the first 5 days of the menstrual cycle).", + "tags": [] + }, + { + "key": "Endometriosis / Heavy Bleeding", + "val": "**PO** 10-30 mg/day for 90 days.", + "tags": [] + }, + { + "key": "Hormone Replacement Therapy (Adjunct)", + "val": "**PO** 2.5-5 mg/day (Added to estrogen to protect the uterine lining).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Depo-Provera (IM), Provera (Oral), Ralovera", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials/Pre-filled syringes (150 mg/1 mL) for deep **IM** or **SC** injection.", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (2.5, 5, 10, 100 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Long-term contraception, heavy menstrual bleeding, endometriosis, endometrial protection in HRT.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The definitive 'forget-proof' contraceptive injection. Often stops periods entirely (amenorrhea) after the first few doses.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Undiagnosed abnormal vaginal bleeding, active breast cancer, severe liver disease.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Existing absolute row names severe liver disease; severe hepatic impairment is the modeled patient-panel match." + } + }, + { + "key": "Pregnancy", + "val": "CONTRAINDICATED — Do not administer if pregnant or suspected pregnancy; exclude pregnancy before depot initiation when timing is uncertain.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Depot medroxyprogesterone should not be administered in known or suspected pregnancy." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong **CYP3A4** inducers (Carbamazepine, Phenytoin) accelerate the clearance of the oral tablets, but the massive 150mg IM depot is generally resistant to clinically failing from this.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Imaging / Consults", + "val": "MONITOR — Reassess ongoing depot use, fracture risk, calcium/vitamin D intake, and weight-bearing exercise; consider BMD assessment in high-risk or prolonged use rather than routine DEXA for all.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Counsel heavily on the delayed return to fertility. Do not prescribe if the patient wishes to get pregnant in the next 12-18 months.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "monitor", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Amenorrhea Goal", + "val": "While the first injection causes frustrating, irregular spotting, by the 3rd or 4th injection, over 50% of women stop bleeding completely. This makes it an incredible therapy for women with severely disabling, painful periods.", + "tags": [] + }, + { + "key": "The Bone Fix", + "val": "Because it stops the ovaries from making estrogen, it puts young women into a mild 'chemical menopause', causing the bones to thin. Ensure adequate dietary calcium and weight-bearing exercise.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits secretion of pituitary gonadotropins, preventing follicular maturation and ovulation. Thins the endometrium and thickens cervical mucus.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IM** Immediate suppression of ovulation.", + "tags": [] + }, + { + "key": "Half-life", + "val": "50 Days (IM depot). Can take up to 10-18 MONTHS for the drug to fully clear and fertility to return.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: DEPO-PROVERA medroxyprogesterone Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Progestin — Highly potent synthetic progestin." + }, + { + "label": "Route / Formulation", + "value": "Vials/Pre-filled syringes (150 mg/1 mL) for deep **IM** or **SC** injection. (Depo-Provera (IM), Provera (Oral), Ralovera)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 150 mg deep gluteal injection EVERY 12 WEEKS. (Must be given within the first 5 days of the menstrual cycle). Max **150 mg every 12 weeks** (**IM**)." + }, + { + "label": "Key Indication Doses", + "value": "Contraception (Depo): **IM** 150 mg deep gluteal injection EVERY 12 WEEKS. (Must be given within the first 5 days of the menstrual cycle). Endometriosis / Heavy Bleeding: **PO** 10-30 mg/day for 90 days. Hormone Replacement Therapy (Adjunct): **PO** 2.5-5 mg/day (Added to estrogen to protect the uterine lining)." + }, + { + "label": "Best Uses", + "value": "Medroxyprogesterone is a progestogen used for contraception (depot injection) and HRT, but the depot form causes significant bone density loss and delayed return of fertility." + }, + { + "label": "Avoid / Cautions", + "value": "Pregnancy, unexplained vaginal bleeding, active/suspected breast cancer, severe liver disease, thromboembolic disease history, and major osteoporosis risk need review. Depot use can reduce BMD and delay return to fertility." + }, + { + "label": "Key Risks", + "value": "Musculoskeletal: Significant decrease in Bone Mineral Density (BMD) due to profound estrogen suppression. Do not use for > 2 years without evaluating fracture risk. Metabolic: Significant weight gain (average 2-3 kg/year), fluid retention. Gynecological: Irregular, unpredictable spotting/bleeding for the first 3-6 months. Delayed return to fertility (up to 18 months)." + }, + { + "label": "Key Interactions", + "value": "Strong **CYP3A4** inducers (Carbamazepine, Phenytoin) accelerate the clearance of the oral tablets, but the massive 150mg IM depot is generally resistant to clinically failing from this." + }, + { + "label": "Monitoring", + "value": "Consider a DEXA scan if a young woman remains on Depo-Provera for more than 2-3 years continuously. Counsel heavily on the delayed return to fertility. Do not prescribe if the patient wishes to get pregnant in the next 12-18 months." + }, + { + "label": "Clinical Pearl", + "value": "While the first injection causes frustrating, irregular spotting, by the 3rd or 4th injection, over 50% of women stop bleeding completely. This makes it an incredible therapy for women with severely disabling, painful periods." + } + ] + }, + { + "slug": "esomeprazole", + "name": "Esomeprazole", + "class": "Acid Suppression", + "subclass": "Proton Pump Inhibitor", + "category": "Gastrointestinal - Acid Suppression", + "accent": "#b45309", + "tag": "PPI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "80 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1-1.5 h", + "cls": "", + "flag": "" + }, + { + "label": "Plavix Interaction", + "value": "AVOID", + "cls": "hi", + "flag": "warn" + }, + { + "label": "C. Diff Risk", + "value": "MODERATE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The S-enantiomer of Omeprazole. Highly potent PPI providing slightly more aggressive acid suppression than Pantoprazole, but carries a dangerous interaction with Clopidogrel.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **80 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never prescribe alongside Clopidogrel due to CYP2C19 inhibition.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Esomeprazole is the most potent PPI with the highest acid suppression, but carries the same long-term risks as all PPIs and should be regularly reviewed for de-prescribing.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "MODERATE — C. difficile infection risk, microscopic colitis.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hypomagnesemia (chronic use).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "GORD / PUD", + "val": "**PO** 20-40 mg **OD** (30 mins before breakfast).", + "tags": [] + }, + { + "key": "Severe Bleeding Ulcer", + "val": "**IV** 80 mg STAT, then 8 mg/hr infusion for 72 hours.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nexium", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Enteric-coated tablets/capsules (20 mg, 40 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (40 mg powder) for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4). Low dose available S2.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "GORD, erosive esophagitis, Zollinger-Ellison syndrome.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Used when highly potent acid suppression is required.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Hypersensitivity to esomeprazole/substituted benzimidazoles; avoid with atazanavir or cilostazol.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Esomeprazole pregnancy row should prompt benefit-risk review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — CYP2C19 inhibition may reduce clopidogrel activation; avoid routine combination where antiplatelet effect is critical and use pantoprazole if a PPI is needed.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Routine Mg2+ checks for long-term users.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Chiral Advantage", + "val": "Because it is the purified S-enantiomer, Esomeprazole undergoes less hepatic first-pass metabolism than standard Omeprazole, delivering more active drug to the proton pumps.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Irreversible inhibition of the H+/K+ ATPase proton pump.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-1.5 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: NEXIUM/esomeprazole Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Proton Pump Inhibitor — The S-enantiomer of Omeprazole." + }, + { + "label": "Route / Formulation", + "value": "Enteric-coated tablets/capsules (20 mg, 40 mg). (Nexium)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 20-40 mg **OD** (30 mins before breakfast). Max **80 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "GORD / PUD: **PO** 20-40 mg **OD** (30 mins before breakfast). Severe Bleeding Ulcer: **IV** 80 mg STAT, then 8 mg/hr infusion for 72 hours." + }, + { + "label": "Best Uses", + "value": "Esomeprazole is the most potent PPI with the highest acid suppression, but carries the same long-term risks as all PPIs and should be regularly reviewed for de-prescribing." + }, + { + "label": "Avoid / Cautions", + "value": "Co-administration with Clopidogrel. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: C. difficile infection risk, microscopic colitis. Metabolic: Hypomagnesemia (chronic use)." + }, + { + "label": "Key Interactions", + "value": "Moderate-to-strong inhibitor of **CYP2C19**. Blocks the activation of Clopidogrel, leading to fatal stent thrombosis. Use Pantoprazole instead." + }, + { + "label": "Monitoring", + "value": "Routine Mg2+ checks for long-term users." + }, + { + "label": "Clinical Pearl", + "value": "Because it is the purified S-enantiomer, Esomeprazole undergoes less hepatic first-pass metabolism than standard Omeprazole, delivering more active drug to the proton pumps." + } + ] + }, + { + "slug": "famotidine", + "name": "Famotidine", + "class": "Acid Suppression", + "subclass": "H2 Receptor Antagonist", + "category": "Gastrointestinal - Acid Suppression", + "accent": "#b45309", + "tag": "H2 ANTAGONIST", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "80 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3 h", + "cls": "", + "flag": "" + }, + { + "label": "CYP Inhibitor", + "value": "NONE", + "cls": "good", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Histamine H2 receptor antagonist. Highly effective acid-suppressor. Unlike its predecessor (Cimetidine), it has zero dangerous liver enzyme interactions, making it incredibly safe for polypharmacy.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **80 mg/day** (e.g., 40 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Predominantly renally cleared. Must halve the dose in severe kidney failure to prevent toxic CNS accumulation (delirium/seizures).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Famotidine is an H2 receptor antagonist for acid suppression with fewer drug interactions than PPIs, but is less potent than PPIs and tolerance develops with regular use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "MODERATE — Confusion, delirium, hallucinations, agitation (Exclusively seen in elderly patients or those with unadjusted renal failure where the drug crosses the BBB).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "LOW — Mild diarrhea or constipation.", + "tags": [] + }, + { + "key": "Haematological", + "val": "RARE — Thrombocytopenia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "GORD / Peptic Ulcer Disease", + "val": "**PO** 20-40 mg **BD** or 40 mg **NOCTE** (Nighttime dosing is highly effective because histamine drives nocturnal acid secretion).", + "tags": [] + }, + { + "key": "Allergic Reactions (Off-Label)", + "val": "**PO** / **IV** 20 mg STAT (Acts as an H2 blocker to adjunct H1 blockers like cetirizine during anaphylaxis/hives).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** < 50, reduce dose to 20 mg **NOCTE** or prolong the interval to 48 hours.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 50 + } + }, + "note": "Famotidine requires dose reduction or interval extension in renal impairment." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Pepzan, Pamacid", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (20 mg, 40 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (20 mg/2 mL) for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4 for 40mg/IV). OTC (S2) for 20mg.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Treatment of gastric and duodenal ulcers, GORD, Zollinger-Ellison syndrome.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Refractory chronic urticaria (hives), adjunct in anaphylaxis protocols.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Step-down therapy from PPIs. The preferred H2 antagonist worldwide after Ranitidine was recalled due to NDMA contamination.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known hypersensitivity to H2 antagonists.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Famotidine pregnancy row is informational/safe-use context and should not trigger a danger alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "SAFE — Unlike Cimetidine (which violently blocks CYP450 enzymes and interacts with Warfarin/Phenytoin), Famotidine has ZERO effect on hepatic CYP enzymes. It is completely safe to mix.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Drugs requiring an acidic gut to absorb (Ketoconazole, Iron) will fail to absorb properly.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **eGFR** in elderly patients before charting standard 40mg BD doses.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "If an elderly patient on Famotidine becomes acutely confused or delirious, withhold the drug immediately; it is likely neurotoxicity from renal accumulation.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Anaphylaxis Adjunct", + "val": "During severe anaphylaxis or full-body hives, blocking the H1 receptor (with Cetirizine/Promethazine) only solves half the problem. ~15% of histamine receptors in the skin and blood vessels are actually H2 receptors. Giving IV Famotidine provides total histamine blockade.", + "tags": [] + }, + { + "key": "Night-Time Dominance", + "val": "Proton Pump Inhibitors (PPIs) are best for daytime, meal-stimulated acid. H2 antagonists (Famotidine) are best for nighttime, fasting acid. If a patient on a morning PPI still wakes up with acid reflux at 2 AM, adding Famotidine 40mg NOCTE is a highly effective combination.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitively blocks the H2 receptor on the basolateral membrane of gastric parietal cells, cutting off the histamine-driven pathway of the H+/K+ ATPase proton pump. Highly effective at blocking basal/nocturnal acid secretion.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1 hour. **IV** Immediate.", + "tags": [] + }, + { + "key": "Duration", + "val": "10-12 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2.5-3.5 hours. Excreted 70% unchanged in the urine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: AUSFAM/famotidine Australian ARTG, CMI, and PBS source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "H2 Receptor Antagonist — Histamine H2 receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (20 mg, 40 mg). (Pepzan, Pamacid)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 20-40 mg **BD** or 40 mg **NOCTE** (Nighttime dosing is highly effective because histamine drives nocturnal acid secretion). Max **80 mg/day** (e.g., 40 mg BD)." + }, + { + "label": "Key Indication Doses", + "value": "GORD / Peptic Ulcer Disease: **PO** 20-40 mg **BD** or 40 mg **NOCTE** (Nighttime dosing is highly effective because histamine drives nocturnal acid secretion). Allergic Reactions (Off-Label): **PO** / **IV** 20 mg STAT (Acts as an H2 blocker to adjunct H1 blockers like cetirizine during anaphylaxis/hives). Renal Impairment: If **eGFR** < 50, reduce dose to 20 mg **NOCTE** or prolong the interval to 48 hours." + }, + { + "label": "Best Uses", + "value": "Famotidine is an H2 receptor antagonist for acid suppression with fewer drug interactions than PPIs, but is less potent than PPIs and tolerance develops with regular use." + }, + { + "label": "Avoid / Cautions", + "value": "Known hypersensitivity to H2 antagonists. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Neurological: Confusion, delirium, hallucinations, agitation (Exclusively seen in elderly patients or those with unadjusted renal failure where the drug crosses the BBB). Gastrointestinal: Mild diarrhea or constipation. Haematological: RARE — Thrombocytopenia." + }, + { + "label": "Key Interactions", + "value": "Unlike Cimetidine (which violently blocks CYP450 enzymes and interacts with Warfarin/Phenytoin), Famotidine has ZERO effect on hepatic CYP enzymes. It is completely safe to mix. Drugs requiring an acidic gut to absorb (Ketoconazole, Iron) will fail to absorb properly." + }, + { + "label": "Monitoring", + "value": "Check **eGFR** in elderly patients before charting standard 40mg BD doses. If an elderly patient on Famotidine becomes acutely confused or delirious, withhold the drug immediately; it is likely neurotoxicity from renal accumulation." + }, + { + "label": "Clinical Pearl", + "value": "During severe anaphylaxis or full-body hives, blocking the H1 receptor (with Cetirizine/Promethazine) only solves half the problem. ~15% of histamine receptors in the skin and blood vessels are actually H2 receptors. Giving IV Famotidine provides total histamine blockade." + } + ] + }, + { + "slug": "pantoprazole", + "name": "Pantoprazole", + "class": "Acid Suppression", + "subclass": "Proton Pump Inhibitor", + "category": "Gastrointestinal - Acid Suppression", + "accent": "#b45309", + "tag": "PPI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "80 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1-2 h", + "cls": "", + "flag": "" + }, + { + "label": "Plavix Interaction", + "value": "SAFE", + "cls": "good", + "flag": "" + }, + { + "label": "C. Diff Risk", + "value": "MODERATE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Irreversible Proton Pump Inhibitor (PPI). Effectively shuts down gastric acid secretion. The preferred PPI on cardiovascular wards due to its safety profile with antiplatelets.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **80 mg/day** (used BD for severe bleeding ulcers or Zollinger-Ellison).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Provides optimal cover for NSAID/Aspirin-induced ulcer prophylaxis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Pantoprazole is a widely used PPI for GORD, peptic ulcers, and stress ulcer prophylaxis with IV availability, but long-term use increases risk of hypomagnesaemia, fractures, and C. difficile.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "MODERATE — Enteric infections (C. difficile, Salmonella) due to loss of acid barrier. Microscopic colitis.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hypomagnesemia, Vitamin B12 deficiency, Iron deficiency (with chronic use > 1 year).", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "MODERATE — Increased risk of osteoporotic fractures with prolonged, high-dose use.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "GORD / PUD Prophylaxis", + "val": "**PO** 20-40 mg **OD** (30 mins before breakfast).", + "tags": [] + }, + { + "key": "Active Bleeding Ulcer", + "val": "**IV** 80 mg STAT bolus, followed by 8 mg/hr infusion for 72 hours.", + "tags": [] + }, + { + "key": "H. Pylori Eradication", + "val": "**PO** 40 mg **BD** (with antibiotics).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Somac, Salpraz", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Enteric-coated tablets (20 mg, 40 mg). Do not crush.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (40 mg powder) for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "GORD, Peptic Ulcer Disease (PUD), GI bleed, stress ulcer prophylaxis in ICU.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The safest PPI to prescribe alongside Clopidogrel.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Co-administration with rilpivirine/atazanavir (HIV meds require acid to absorb).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Pantoprazole pregnancy row should prompt benefit-risk review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Unlike Omeprazole, Pantoprazole does NOT significantly inhibit CYP2C19. It is completely safe to use with Clopidogrel.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Drugs requiring acidic pH for absorption (e.g., Ketoconazole, Itraconazole, Iron) will fail to absorb.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Check **U&E** (magnesium) and B12 levels if the patient has been on a PPI for years.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Review the medication chart constantly. Cease the PPI if there is no longer a strict indication to prevent chronic toxicity.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Breakfast Rule", + "val": "PPIs only bind to ACTIVE proton pumps. Pumps are activated by eating. Therefore, taking a PPI 30 mins *before* breakfast ensures the drug peaks in the blood exactly when the most pumps are turned on. Taking it at night or without food wastes the drug.", + "tags": [] + }, + { + "key": "Rebound Hypersecretion", + "val": "If a patient has been on a PPI for > 2 months, abruptly stopping it will cause massive rebound acid hypersecretion and severe heartburn. It must be tapered down (e.g., to alternate days) before ceasing.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug activated in the acidic canaliculi of gastric parietal cells. Irreversibly binds and inhibits the H+/K+ ATPase pump, halting acid secretion.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2.5 hours. **IV** 15-30 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h (Pump inhibition is irreversible, requires synthesis of new pumps).", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-2 hours (Drug clears fast, but effect lasts days).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: SOMAC/pantoprazole Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Proton Pump Inhibitor — Irreversible Proton Pump Inhibitor (PPI)." + }, + { + "label": "Route / Formulation", + "value": "Enteric-coated tablets (20 mg, 40 mg). Do not crush. (Somac, Salpraz)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 20-40 mg **OD** (30 mins before breakfast). Max **80 mg/day** (used BD for severe bleeding ulcers or Zollinger-Ellison)." + }, + { + "label": "Key Indication Doses", + "value": "GORD / PUD Prophylaxis: **PO** 20-40 mg **OD** (30 mins before breakfast). Active Bleeding Ulcer: **IV** 80 mg STAT bolus, followed by 8 mg/hr infusion for 72 hours. H. Pylori Eradication: **PO** 40 mg **BD** (with antibiotics)." + }, + { + "label": "Best Uses", + "value": "Pantoprazole is a widely used PPI for GORD, peptic ulcers, and stress ulcer prophylaxis with IV availability, but long-term use increases risk of hypomagnesaemia, fractures, and C. difficile." + }, + { + "label": "Avoid / Cautions", + "value": "Co-administration with rilpivirine/atazanavir (HIV meds require acid to absorb). **Pregnancy** Category B3 (Omeprazole is Category B3 but has more safety data)." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Enteric infections (C. difficile, Salmonella) due to loss of acid barrier. Microscopic colitis. Metabolic: Hypomagnesemia, Vitamin B12 deficiency, Iron deficiency (with chronic use > 1 year). Musculoskeletal: Increased risk of osteoporotic fractures with prolonged, high-dose use." + }, + { + "label": "Key Interactions", + "value": "Unlike Omeprazole, Pantoprazole does NOT significantly inhibit CYP2C19. It is completely safe to use with Clopidogrel. Drugs requiring acidic pH for absorption (e.g., Ketoconazole, Itraconazole, Iron) will fail to absorb." + }, + { + "label": "Monitoring", + "value": "Check **U&E** (magnesium) and B12 levels if the patient has been on a PPI for years. Review the medication chart constantly. Cease the PPI if there is no longer a strict indication to prevent chronic toxicity." + }, + { + "label": "Clinical Pearl", + "value": "PPIs only bind to ACTIVE proton pumps. Pumps are activated by eating. Therefore, taking a PPI 30 mins *before* breakfast ensures the drug peaks in the blood exactly when the most pumps are turned on. Taking it at night or without food wastes the drug." + } + ] + }, + { + "slug": "cyclizine", + "name": "Cyclizine", + "class": "Antiemetic", + "subclass": "Antihistamine", + "category": "Gastrointestinal - Antiemetics", + "accent": "#b45309", + "tag": "ANTIEMETIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "150 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "20 h", + "cls": "", + "flag": "" + }, + { + "label": "Heart Failure", + "value": "CAUTION", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Anticholinergic", + "value": "HIGH", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "First-generation antihistamine with strong anticholinergic properties. Highly effective for motion sickness, vestibular nausea, and opioid-induced nausea.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **150 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Cyclizine drops cardiac output (negative inotrope). Use with extreme caution in severe heart failure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Cyclizine is a first-line antiemetic for vestibular and opioid-induced nausea, but causes sedation and anticholinergic effects and must be avoided in heart failure (reduces cardiac output).", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Tachycardia, hypotension, negative inotropy (decreases heart contractility).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Drowsiness, sedation, confusion (especially in the elderly).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Dry mouth, urinary retention, blurred vision (classic anticholinergic toxidrome).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Nausea / Vomiting", + "val": "**PO** / **IV** / **IM** 50 mg up to **TDS**. Max 150 mg/day.", + "tags": [] + }, + { + "key": "Palliative Care", + "val": "Continuous **SC** infusion via syringe driver (e.g., 100-150 mg over 24h).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Valoid, Nausicalm", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (50 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (50 mg/1 mL) for **IV** / **IM** / **SC**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S3 PO). Prescription (S4 Ampoules).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "PONV, motion sickness, palliative care nausea, inner ear pathology.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Excellent second-line agent when Ondansetron fails or causes intolerable constipation/headache.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Hypersensitivity. Avoid or use specialist caution in acute MI, severe heart failure, urinary retention/prostatic hypertrophy, glaucoma, obstructive GI disease, and severe hepatic impairment because anticholinergic or cardiovascular toxicity may worsen.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "caution", + "severity": "caution", + "match": { + "hepatic": ["severe"] + }, + "note": "Cyclizine may need avoidance or specialist caution in severe hepatic impairment." + } + }, + { + "key": "Ocular", + "val": "CAUTION — Narrow-angle glaucoma.", + "tags": [] + }, + { + "key": "Elderly", + "val": "CAUTION — Older adults are more prone to anticholinergic delirium, falls, constipation, urinary retention, and sedation; avoid routine use unless benefit clearly outweighs risk.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "caution", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Cyclizine anticholinergic burden is high risk in older adults." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive sedation and anticholinergic toxicity with opioids, benzodiazepines, alcohol, TCAs, antipsychotics, promethazine, oxybutynin, and other antimuscarinics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for tachycardia and signs of acute heart failure decompensation.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor bladder output in elderly males.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Heart Failure Trap", + "val": "Because cyclizine is a direct negative inotrope, giving 50 mg IV to a patient with a brittle ejection fraction can push them into acute pulmonary oedema. Use Metoclopramide or Ondansetron instead.", + "tags": [] + }, + { + "key": "Syringe Driver Caution", + "val": "In palliative care, Cyclizine is notorious for crystallizing in syringe drivers if mixed with certain drugs (like Clonazepam or Haloperidol). Consult palliative guidelines before mixing.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "H1 receptor antagonist with potent antimuscarinic (anticholinergic) activity. Blocks histamine and acetylcholine in the vomiting center and vestibular apparatus.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins. **IV** 5 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "20 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NAUSICALM cyclizine Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Antihistamine — First-generation antihistamine with strong anticholinergic properties." + }, + { + "label": "Route / Formulation", + "value": "Tablets (50 mg). (Valoid, Nausicalm)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** / **IV** / **IM** 50 mg up to **TDS**. Max 150 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Nausea / Vomiting: **PO** / **IV** / **IM** 50 mg up to **TDS**. Max 150 mg/day. Palliative Care: Continuous **SC** infusion via syringe driver (e.g., 100-150 mg over 24h)." + }, + { + "label": "Best Uses", + "value": "Cyclizine is a first-line antiemetic for vestibular and opioid-induced nausea, but causes sedation and anticholinergic effects and must be avoided in heart failure (reduces cardiac output)." + }, + { + "label": "Avoid / Cautions", + "value": "Severe uncompensated heart failure, acute MI." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Tachycardia, hypotension, negative inotropy (decreases heart contractility). Neurological: Drowsiness, sedation, confusion (especially in the elderly). Gastrointestinal: Dry mouth, urinary retention, blurred vision (classic anticholinergic toxidrome)." + }, + { + "label": "Key Interactions", + "value": "Additive anticholinergic effects with TCAs, antipsychotics, and Ipratropium. Additive sedation with opioids/benzos." + }, + { + "label": "Monitoring", + "value": "Monitor for tachycardia and signs of acute heart failure decompensation. Monitor bladder output in elderly males." + }, + { + "label": "Clinical Pearl", + "value": "Because cyclizine is a direct negative inotrope, giving 50 mg IV to a patient with a brittle ejection fraction can push them into acute pulmonary oedema. Use Metoclopramide or Ondansetron instead." + } + ] + }, + { + "slug": "domperidone", + "name": "Domperidone", + "class": "Antiemetic", + "subclass": "Peripheral D2 Antagonist", + "category": "Gastrointestinal - Antiemetics", + "accent": "#b45309", + "tag": "ANTIEMETIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "30 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "7-9 h", + "cls": "", + "flag": "" + }, + { + "label": "QTc Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "BBB Penetration", + "value": "NONE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Peripheral dopamine D2 antagonist. Highly effective prokinetic and antiemetic. Crucially, it does NOT cross the blood-brain barrier, making it completely free of psychiatric or EPSE side effects.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **30 mg/day** (Strictly enforced by TGA/EMA due to cardiac risks).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The ONLY anti-nausea medication safe to prescribe to patients with Parkinson's Disease. However, carries a black box warning for fatal ventricular arrhythmias.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Domperidone is a peripheral dopamine antagonist antiemetic and prokinetic that does not cross the blood-brain barrier, but prolongs QTc and carries cardiovascular risk especially in elderly.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — **QTc** prolongation, ventricular fibrillation, sudden cardiac death (Risk increases exponentially at doses > 30 mg/day or age > 60).", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Endocrine", + "val": "HIGH — Hyperprolactinemia (galactorrhea, amenorrhea).", + "tags": [] + }, + { + "key": "Neurological", + "val": "SAFE — Zero EPSE, zero akathisia, zero sedation.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Nausea / Gastroparesis", + "val": "**PO** 10 mg up to **TDS**. Must be taken 15-30 mins BEFORE meals to exert prokinetic effect. Max 30 mg/day.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce dose frequency to **OD** or **BD** if **eGFR** < 30.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Domperidone renal impairment should prompt dose-frequency reduction/review." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Motilium", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Restricted to 1-week supply in many jurisdictions to prevent chronic cardiac toxicity.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Nausea and vomiting, diabetic gastroparesis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Stimulation of lactation (galactagogue) in breastfeeding mothers.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The mandatory antiemetic for Parkinson's patients (as Metoclopramide and Prochlorperazine will paralyze them).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Baseline **QTc** > 450 ms, significant heart disease, severe hepatic impairment, mechanical bowel obstruction.", + "tags": [], + "patient": { + "factors": ["hepatic", "qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2. Lactation use as a galactagogue is off-label and requires careful cardiac/QT risk review.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "Domperidone pregnancy/lactation row requires benefit-risk and QT/cardiac review; it is not an automatic pregnancy contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Strong **CYP3A4** inhibitors (Clarithromycin, Ketoconazole) block clearance, spiking Domperidone levels and causing lethal arrhythmias. DO NOT COMBINE.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Amiodarone, Sotalol, SSRIs (Additive QTc prolongation).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG** before prescribing, particularly in patients over 60 or those with a history of cardiac disease.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Parkinson's Shield", + "val": "If a patient on Levodopa develops severe nausea, giving them Metoclopramide will strip the dopamine off their brain receptors, causing an acute Parkinsonian crisis. Domperidone only blocks dopamine in the gut, curing the nausea while preserving brain function.", + "tags": [] + }, + { + "key": "The Breast Milk Hack", + "val": "Domperidone heavily blocks dopamine's inhibitory effect on the pituitary gland, leading to a massive surge in prolactin. It is widely prescribed by lactation consultants to boost breast milk supply in struggling mothers.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Blocks peripheral D2 receptors in the gut (enhancing peristalsis) and in the Chemoreceptor Trigger Zone (which sits *outside* the BBB).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "7-9 hours. Extensively metabolised by CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: MOTILIUM/domperidone Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Peripheral D2 Antagonist — Peripheral dopamine D2 antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg). (Motilium)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10 mg up to **TDS**. Must be taken 15-30 mins BEFORE meals to exert prokinetic effect. Max 30 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Nausea / Gastroparesis: **PO** 10 mg up to **TDS**. Must be taken 15-30 mins BEFORE meals to exert prokinetic effect. Max 30 mg/day. Renal Impairment: Reduce dose frequency to **OD** or **BD** if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Domperidone is a peripheral dopamine antagonist antiemetic and prokinetic that does not cross the blood-brain barrier, but prolongs QTc and carries cardiovascular risk especially in elderly." + }, + { + "label": "Avoid / Cautions", + "value": "Baseline **QTc** > 450 ms, significant heart disease, severe hepatic impairment, mechanical bowel obstruction. **Pregnancy** Category B2. Often prescribed off-label postpartum for lactation." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: **QTc** prolongation, ventricular fibrillation, sudden cardiac death (Risk increases exponentially at doses > 30 mg/day or age > 60). Endocrine: Hyperprolactinemia (galactorrhea, amenorrhea). Neurological: Zero EPSE, zero akathisia, zero sedation." + }, + { + "label": "Key Interactions", + "value": "Strong **CYP3A4** inhibitors (Clarithromycin, Ketoconazole) block clearance, spiking Domperidone levels and causing lethal arrhythmias. DO NOT COMBINE. Amiodarone, Sotalol, SSRIs (Additive QTc prolongation)." + }, + { + "label": "Monitoring", + "value": "Baseline **ECG** before prescribing, particularly in patients over 60 or those with a history of cardiac disease." + }, + { + "label": "Clinical Pearl", + "value": "If a patient on Levodopa develops severe nausea, giving them Metoclopramide will strip the dopamine off their brain receptors, causing an acute Parkinsonian crisis. Domperidone only blocks dopamine in the gut, curing the nausea while preserving brain function." + } + ] + }, + { + "slug": "hyoscine-hydrobromide", + "name": "Hyoscine hydrobromide", + "class": "Antiemetic", + "subclass": "Anticholinergic", + "category": "Gastrointestinal - Antiemetics", + "accent": "#b45309", + "tag": "ANTIEMETIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1.5 mg Patch/72h", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "9.5 h", + "cls": "", + "flag": "" + }, + { + "label": "Sedation", + "value": "PROFOUND", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Anticholinergic", + "value": "CRITICAL RISK", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Centrally acting, highly lipid-soluble antimuscarinic agent. The most effective drug for severe motion sickness and drying up terminal palliative secretions.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1.5 mg patch every 72 hours** (Topical) or **1.2 mg/day** (Oral/IV).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Unlike Hyoscine Butylbromide (Buscopan), Hydrobromide (Kwells) rapidly crosses the blood-brain barrier, causing profound sedation and delirium.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Hyoscine hydrobromide is an anticholinergic used for motion sickness and palliative secretion management, but crosses the blood-brain barrier causing sedation and confusion unlike hyoscine butylbromide.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Toxic delirium, hallucinations, profound sedation, severe confusion (especially in the elderly).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe dry mouth, constipation, paralytic ileus.", + "tags": [] + }, + { + "key": "Ocular", + "val": "HIGH — Blurred vision, pupillary dilation (mydriasis).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Motion Sickness", + "val": "**Topical** Apply 1 patch (1.5 mg) behind the ear 5-6 hours before travel. Leave on for 72 hours. OR **PO** 300 mcg STAT.", + "tags": [] + }, + { + "key": "Palliative Care (Secretions)", + "val": "**SC** / **IV** 400 mcg q4h PRN or via 24-hour syringe driver (1.2 - 2.4 mg/24h).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Kwells, Scopoderm (Patch)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (300 mcg).", + "tags": [] + }, + { + "key": "Topical", + "val": "Transdermal patch (1.5 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (400 mcg/1 mL) for **SC** / **IM** / **IV**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S2). Palliative ampoules are S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention of motion sickness, control of 'death rattle' (excessive respiratory secretions) in palliative care.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line for severe motion/sea sickness. Cornerstone of end-of-life care pathways.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Avoid in narrow-angle glaucoma, urinary retention/prostatic obstruction, pyloric stenosis or obstructive GI disease, myasthenia gravis, and significant tachyarrhythmia unless specialist-directed.", + "tags": [] + }, + { + "key": "Elderly", + "val": "CRITICAL — High risk of confusion, falls, urinary retention, constipation, blurred vision, and delirium in older adults; avoid routine motion-sickness use and reserve palliative use for clear benefit.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "caution", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Hyoscine hydrobromide has high central anticholinergic toxicity risk in older adults." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive anticholinergic and CNS-depressant effects with TCAs, antipsychotics, promethazine, oxybutynin, benzodiazepines, opioids, and alcohol.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the patch is applied to a clean, hairless area behind the ear. Warn patients to wash their hands immediately after applying the patch, or they will accidentally dilate their own pupil if they rub their eye.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Name Trap", + "val": "Hyoscine HYDRObromide (Kwells/Scopoderm) crosses the BBB and puts you to sleep. Hyoscine BUTYLbromide (Buscopan) stays in the gut and fixes stomach cramps. Confusing them on the ward will result in a delirious or seizing patient.", + "tags": [] + }, + { + "key": "The Palliative Patch", + "val": "A Scopoderm patch behind the ear of a dying patient is a painless, non-invasive way to completely dry up the distressing rattling airway secretions without needing regular needles.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive antagonist of central and peripheral muscarinic receptors. Blocks transmission from the vestibular nuclei to the CNS vomiting center. Dries up salivary and respiratory glands.", + "tags": [] + }, + { + "key": "Onset", + "val": "**Topical** 4-6 hours. **SC** 15-30 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "72 h (Patch).", + "tags": [] + }, + { + "key": "Half-life", + "val": "9.5 hours. Extensively metabolised by the liver.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: KWELLS hyoscine hydrobromide Australian medicine-information source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Anticholinergic — Centrally acting, highly lipid-soluble antimuscarinic agent." + }, + { + "label": "Route / Formulation", + "value": "Tablets (300 mcg). (Kwells, Scopoderm (Patch))" + }, + { + "label": "Usual Dose & Max", + "value": "**Topical** Apply 1 patch (1.5 mg) behind the ear 5-6 hours before travel. Leave on for 72 hours. OR **PO** 300 mcg STAT. Max **1.5 mg patch every 72 hours** (Topical) or **1.2 mg/day** (Oral/IV)." + }, + { + "label": "Key Indication Doses", + "value": "Motion Sickness: **Topical** Apply 1 patch (1.5 mg) behind the ear 5-6 hours before travel. Leave on for 72 hours. OR **PO** 300 mcg STAT. Palliative Care (Secretions): **SC** / **IV** 400 mcg q4h PRN or via 24-hour syringe driver (1.2 - 2.4 mg/24h)." + }, + { + "label": "Best Uses", + "value": "Hyoscine hydrobromide is an anticholinergic used for motion sickness and palliative secretion management, but crosses the blood-brain barrier causing sedation and confusion unlike hyoscine butylbromide." + }, + { + "label": "Avoid / Cautions", + "value": "Narrow-angle glaucoma (will precipitate acute blindness), severe BPH with urinary retention." + }, + { + "label": "Key Risks", + "value": "Neurological: Toxic delirium, hallucinations, profound sedation, severe confusion (especially in the elderly). Gastrointestinal: Severe dry mouth, constipation, paralytic ileus. Ocular: Blurred vision, pupillary dilation (mydriasis)." + }, + { + "label": "Key Interactions", + "value": "TCAs, Promethazine, Olanzapine. Additive anticholinergic burden causes fatal hyperthermia and toxic megacolon." + }, + { + "label": "Monitoring", + "value": "Ensure the patch is applied to a clean, hairless area behind the ear. Warn patients to wash their hands immediately after applying the patch, or they will accidentally dilate their own pupil if they rub their eye." + }, + { + "label": "Clinical Pearl", + "value": "Hyoscine HYDRObromide (Kwells/Scopoderm) crosses the BBB and puts you to sleep. Hyoscine BUTYLbromide (Buscopan) stays in the gut and fixes stomach cramps. Confusing them on the ward will result in a delirious or seizing patient." + } + ] + }, + { + "slug": "metoclopramide", + "name": "Metoclopramide", + "class": "Antiemetic", + "subclass": "D2 Antagonist", + "category": "Gastrointestinal - Antiemetics", + "accent": "#b45309", + "tag": "PROKINETIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "30 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5-6 h", + "cls": "", + "flag": "" + }, + { + "label": "EPSE / Akathisia", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Bowel Obstruction", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Central D2 receptor antagonist with peripheral prokinetic properties. Excellent for nausea related to migraines, gastroparesis, and opioid use.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **30 mg/day** (Strict warning by TGA/EMA due to neurological toxicity at higher/prolonged doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never use in patients with bowel obstruction. Limit use to < 5 days to prevent tardive dyskinesia.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Metoclopramide is an effective prokinetic antiemetic for gastroparesis and post-operative nausea, but carries serious risk of extrapyramidal side effects especially in young women and must be limited to 5 days.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Extrapyramidal side effects (EPSE): acute dystonia (oculogyric crisis, torticollis), severe akathisia (restlessness). Tardive dyskinesia with chronic use.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Hypotension, rare bradycardia if pushed too fast IV.", + "tags": [] + }, + { + "key": "Endocrine", + "val": "MODERATE — Hyperprolactinemia (galactorrhea).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Nausea / Vomiting", + "val": "**PO** / **IV** / **IM** 10 mg up to **TDS**. Max 30 mg/day.", + "tags": [] + }, + { + "key": "Diabetic Gastroparesis", + "val": "**PO** 10 mg TDS, 30 mins before meals.", + "tags": [] + }, + { + "key": "Elderly / Renal", + "val": "MANDATORY — Max 5 mg per dose to prevent severe EPSE and confusion.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Maxolon, Pramin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (10 mg/2 mL) for **IV** / **IM**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Nausea/vomiting, gastroparesis, migraine-associated nausea.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line prokinetic antiemetic. Highly effective for opioid-induced nausea (which stimulates the chemoreceptor trigger zone).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Mechanical bowel obstruction, GI perforation/haemorrhage, Parkinson's disease, history of tardive dyskinesia.", + "tags": [] + }, + { + "key": "Age < 20", + "val": "CAUTION — Extremely high risk of acute dystonia in young adults and children. Avoid if possible.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Metoclopramide pregnancy row is informational/safe-use context and should not trigger a danger alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Antipsychotics (Haloperidol, Risperidone). Massively amplifies EPSE and Neuroleptic Malignant Syndrome (NMS) risk.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Anticholinergics (e.g., Amitriptyline) completely cancel out the prokinetic gut effects of metoclopramide.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for akathisia. If a patient starts pacing the ward or pulling out their IV lines after a dose, it is akathisia, not 'anxiety'.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** to guide dose reduction.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Obstruction Trap", + "val": "Because metoclopramide forces the stomach and bowel to contract (prokinetic), giving it to a patient with a mechanical bowel obstruction can cause a catastrophic bowel perforation. Use Ondansetron instead.", + "tags": [] + }, + { + "key": "The Antidote", + "val": "If a young patient develops a terrifying acute dystonia (neck spasming back, eyes rolling up) after IV Maxolon, give Benzatropine 1-2 mg IV/IM STAT to rapidly reverse it.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Blocks D2 dopamine receptors in the Chemoreceptor Trigger Zone (CTZ) of the medulla. Peripherally, it sensitises tissues to acetylcholine, increasing gastric emptying and lower esophageal sphincter tone (prokinetic).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins. **IV** 1-3 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "1-2 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5-6 hours (Renally cleared).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: MAXOLON/metoclopramide Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "D2 Antagonist — Central D2 receptor antagonist with peripheral prokinetic properties." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg). (Maxolon, Pramin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** / **IV** / **IM** 10 mg up to **TDS**. Max 30 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Nausea / Vomiting: **PO** / **IV** / **IM** 10 mg up to **TDS**. Max 30 mg/day. Diabetic Gastroparesis: **PO** 10 mg TDS, 30 mins before meals. Elderly / Renal: Max 5 mg per dose to prevent severe EPSE and confusion." + }, + { + "label": "Best Uses", + "value": "Metoclopramide is an effective prokinetic antiemetic for gastroparesis and post-operative nausea, but carries serious risk of extrapyramidal side effects especially in young women and must be limited to 5 days." + }, + { + "label": "Avoid / Cautions", + "value": "Mechanical bowel obstruction, GI perforation/haemorrhage, Parkinson's disease, history of tardive dyskinesia. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Neurological: Extrapyramidal side effects (EPSE): acute dystonia (oculogyric crisis, torticollis), severe akathisia (restlessness). Tardive dyskinesia with chronic use. Cardiovascular: Hypotension, rare bradycardia if pushed too fast IV. Endocrine: Hyperprolactinemia (galactorrhea)." + }, + { + "label": "Key Interactions", + "value": "Antipsychotics (Haloperidol, Risperidone). Massively amplifies EPSE and Neuroleptic Malignant Syndrome (NMS) risk. Anticholinergics (e.g., Amitriptyline) completely cancel out the prokinetic gut effects of metoclopramide." + }, + { + "label": "Monitoring", + "value": "Monitor for akathisia. If a patient starts pacing the ward or pulling out their IV lines after a dose, it is akathisia, not 'anxiety'. Check **eGFR** to guide dose reduction." + }, + { + "label": "Clinical Pearl", + "value": "Because metoclopramide forces the stomach and bowel to contract (prokinetic), giving it to a patient with a mechanical bowel obstruction can cause a catastrophic bowel perforation. Use Ondansetron instead." + } + ] + }, + { + "slug": "ondansetron", + "name": "Ondansetron", + "class": "Antiemetic", + "subclass": "5HT3 Antagonist", + "category": "Gastrointestinal - Antiemetics", + "accent": "#b45309", + "tag": "ANTIEMETIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "32 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3-4 h", + "cls": "", + "flag": "" + }, + { + "label": "QTc Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Constipation", + "value": "SEVERE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent, central and peripheral 5-HT3 receptor antagonist. The gold standard for chemotherapy and post-operative nausea and vomiting (PONV).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **32 mg/day** (Max 16 mg per single IV dose to limit QTc prolongation).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Causes profound, concrete-like constipation. Co-prescribe laxatives if used for more than 24 hours.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ondansetron is the gold-standard antiemetic for chemotherapy, post-operative, and severe nausea, but prolongs QTc and causes constipation which can be significant.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Severe constipation, bowel impaction.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — **QTc** prolongation, potentially leading to Torsades de Pointes (especially with rapid IV bolus).", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "MODERATE — Headache (very common, up to 20%), dizziness.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Nausea / Vomiting (General)", + "val": "**PO** / **IV** 4-8 mg **BD** or **TDS**. Max 32 mg/day.", + "tags": [] + }, + { + "key": "Chemotherapy Nausea", + "val": "**PO** / **IV** 8 mg 1-2 hours before therapy, then 8 mg **BD**.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "MANDATORY — Max **8 mg/day** in severe **Hepatic** impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "hepatic": ["severe"] + }, + "note": "Ondansetron severe hepatic impairment requires an 8 mg/day maximum." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zofran, Zydis (wafers)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (4 mg, 8 mg). Wafers/ODT (4 mg, 8 mg) — excellent for actively vomiting patients.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (4 mg/2 mL, 8 mg/4 mL) for **IV** / **IM**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for specific chemotherapy/radiotherapy/PONV indications.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Chemo/radiotherapy induced nausea, post-operative nausea, severe gastroenteritis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The most effective, non-sedating, non-EPSE antiemetic on the ward. Preferred over Maxolon in bowel obstruction.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Co-administration with Apomorphine. Congenital Long QT syndrome.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1. Small absolute oral-cleft signal has been reported with first-trimester exposure; review indication and alternatives.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Ondansetron pregnancy row should prompt first-trimester benefit-risk review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Other QTc prolonging drugs (Amiodarone, Haloperidol, SSRIs, Macrolides).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "MODERATE — Serotonergic drugs. Very rare risk of serotonin syndrome.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG** if giving IV or if the patient is on other QTc prolonging meds.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "Monitor bowel movements. Prophylactic laxatives (Movicol) are heavily advised.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Constipation Brick", + "val": "Ondansetron shuts down gut motility (via 5HT3 blockade). If you give this to an opioid-dependent post-op patient without a laxative, they will develop a severe bowel impaction.", + "tags": [] + }, + { + "key": "Wafer Magic", + "val": "The Zydis wafers dissolve on the tongue in seconds and are absorbed rapidly via the oral mucosa. Use these for patients actively vomiting who cannot keep a tablet down.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selectively blocks 5-HT3 (Serotonin) receptors centrally in the Chemoreceptor Trigger Zone and peripherally on vagal nerve terminals in the gut.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30 mins. **IV** 1-5 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "8 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-4 hours (Hepatically metabolised by CYP3A4).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ZOFRAN/ondansetron Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "5HT3 Antagonist — Highly potent, central and peripheral 5-HT3 receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (4 mg, 8 mg). Wafers/ODT (4 mg, 8 mg) — excellent for actively vomiting patients. (Zofran, Zydis (wafers))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** / **IV** 4-8 mg **BD** or **TDS**. Max 32 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Nausea / Vomiting (General): **PO** / **IV** 4-8 mg **BD** or **TDS**. Max 32 mg/day. Chemotherapy Nausea: **PO** / **IV** 8 mg 1-2 hours before therapy, then 8 mg **BD**. Hepatic Impairment: Max **8 mg/day** in severe **Hepatic** impairment." + }, + { + "label": "Best Uses", + "value": "Ondansetron is the gold-standard antiemetic for chemotherapy, post-operative, and severe nausea, but prolongs QTc and causes constipation which can be significant." + }, + { + "label": "Avoid / Cautions", + "value": "Co-administration with Apomorphine. Congenital Long QT syndrome. **Pregnancy** Category B1. Small absolute risk of oral clefts if used in 1st trimester; generally safe later." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe constipation, bowel impaction. Cardiovascular: **QTc** prolongation, potentially leading to Torsades de Pointes (especially with rapid IV bolus). Neurological: Headache (very common, up to 20%), dizziness." + }, + { + "label": "Key Interactions", + "value": "Other QTc prolonging drugs (Amiodarone, Haloperidol, SSRIs, Macrolides). Serotonergic drugs. Very rare risk of serotonin syndrome." + }, + { + "label": "Monitoring", + "value": "Baseline **ECG** if giving IV or if the patient is on other QTc prolonging meds. Monitor bowel movements. Prophylactic laxatives (Movicol) are heavily advised." + }, + { + "label": "Clinical Pearl", + "value": "Ondansetron shuts down gut motility (via 5HT3 blockade). If you give this to an opioid-dependent post-op patient without a laxative, they will develop a severe bowel impaction." + } + ] + }, + { + "slug": "prochlorperazine", + "name": "Prochlorperazine", + "class": "Antiemetic", + "subclass": "D2 Antagonist", + "category": "Gastrointestinal - Antiemetics", + "accent": "#b45309", + "tag": "ANTIEMETIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6-8 h", + "cls": "", + "flag": "" + }, + { + "label": "EPSE / Akathisia", + "value": "RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Phenothiazine antiemetic and antipsychotic. Highly effective central dopamine antagonist. The traditional drug of choice for vertigo and severe labyrinthitis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Like Metoclopramide, it blocks D2 receptors and can cause severe extrapyramidal side effects (EPSE), including acute dystonia in young patients.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Prochlorperazine is a phenothiazine antiemetic effective for nausea, vertigo, and migraine, but causes extrapyramidal side effects and is contraindicated in children under 12 due to dystonic reactions.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Acute dystonia, akathisia, tardive dyskinesia (with prolonged use). HIGH — Sedation, lethargy.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Orthostatic hypotension (due to alpha-1 blockade).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Dry mouth, constipation (anticholinergic effect).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Nausea / Vertigo", + "val": "**PO** 5-10 mg **TDS** or **QID** (Max 20 mg/day).", + "tags": [] + }, + { + "key": "Severe Acute Vertigo", + "val": "**IM** 12.5 mg STAT (Deep IM injection only).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Start at **PO** 5 mg **BD** due to intense sedation and orthostatic hypotension risks.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Stemetil, Stemzine", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg). Buccal tablets (3 mg - Stemzine).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (12.5 mg/1 mL) for **IM** use. Suppositories for **PR** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Nausea and vomiting, vertigo, Meniere's disease.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line agent for vestibular/inner-ear causes of nausea. Less effective for chemotherapy or gut-related nausea than Ondansetron.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Parkinson's disease, severe CNS depression, known hypersensitivity to phenothiazines.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C. Avoid late pregnancy where possible because neonatal EPSE/withdrawal may occur.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Prochlorperazine pregnancy row should prompt benefit-risk and late-pregnancy neonatal-effect review rather than automatic contraindication." + } + }, + { + "key": "Paediatric", + "val": "CAUTION — Avoid in young children and use extreme caution in adolescents/young adults because acute dystonia is more likely.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "caution", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Prochlorperazine has higher acute dystonia risk in paediatric and young patients." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Other D2 antagonists (Haloperidol, Metoclopramide) vastly increase risk of Neuroleptic Malignant Syndrome (NMS) and severe EPSE.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive sedation with Opioids/Benzodiazepines.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **BP** for postural drops. If a young patient develops a stiff neck or locked jaw, give IV Benzatropine immediately (acute dystonia).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Buccal Bypass", + "val": "Stemzine (buccal tablet) is placed high up between the upper lip and gum. It absorbs directly into the bloodstream, bypassing the liver. This makes a tiny 3mg buccal dose as effective as a 10mg swallowed tablet, and perfect for vomiting patients.", + "tags": [] + }, + { + "key": "Not for Kids", + "val": "Due to an extremely high risk of terrifying acute dystonic reactions, avoid using prochlorperazine in children and young adults (<20 years) unless absolutely necessary.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Strongly blocks dopamine D2 receptors in the Chemoreceptor Trigger Zone (CTZ). Also exhibits significant anticholinergic and alpha-1 blocking properties (causing sedation/hypotension).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-40 mins. **IM** 10-20 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "6-8 hours. Hepatically metabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: STEMETIL/prochlorperazine Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "D2 Antagonist — Phenothiazine antiemetic and antipsychotic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg). Buccal tablets (3 mg - Stemzine). (Stemetil, Stemzine)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5-10 mg **TDS** or **QID** (Max 20 mg/day)." + }, + { + "label": "Key Indication Doses", + "value": "Nausea / Vertigo: **PO** 5-10 mg **TDS** or **QID** (Max 20 mg/day). Severe Acute Vertigo: **IM** 12.5 mg STAT (Deep IM injection only). Elderly / Frail: Start at **PO** 5 mg **BD** due to intense sedation and orthostatic hypotension risks." + }, + { + "label": "Best Uses", + "value": "Prochlorperazine is a phenothiazine antiemetic effective for nausea, vertigo, and migraine, but causes extrapyramidal side effects and is contraindicated in children under 12 due to dystonic reactions." + }, + { + "label": "Avoid / Cautions", + "value": "Parkinson's disease, severe CNS depression, known hypersensitivity to phenothiazines. **Pregnancy** Category C. (Avoid late in pregnancy to prevent neonatal EPSE)." + }, + { + "label": "Key Risks", + "value": "Neurological: Acute dystonia, akathisia, tardive dyskinesia (with prolonged use). HIGH — Sedation, lethargy. Cardiovascular: Orthostatic hypotension (due to alpha-1 blockade). Gastrointestinal: Dry mouth, constipation (anticholinergic effect)." + }, + { + "label": "Key Interactions", + "value": "Other D2 antagonists (Haloperidol, Metoclopramide) vastly increase risk of Neuroleptic Malignant Syndrome (NMS) and severe EPSE. Additive sedation with Opioids/Benzodiazepines." + }, + { + "label": "Monitoring", + "value": "Monitor **BP** for postural drops. If a young patient develops a stiff neck or locked jaw, give IV Benzatropine immediately (acute dystonia)." + }, + { + "label": "Clinical Pearl", + "value": "Stemzine (buccal tablet) is placed high up between the upper lip and gum. It absorbs directly into the bloodstream, bypassing the liver. This makes a tiny 3mg buccal dose as effective as a 10mg swallowed tablet, and perfect for vomiting patients." + } + ] + }, + { + "slug": "hyoscine-butylbromide", + "name": "Hyoscine butylbromide", + "class": "Antispasmodic", + "subclass": "Anticholinergic", + "category": "Gastrointestinal - IBD & Antidiarrhoeals", + "accent": "#b45309", + "tag": "ANTISPASMODIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "100 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5 h", + "cls": "", + "flag": "" + }, + { + "label": "BBB Penetration", + "value": "POOR", + "cls": "good", + "flag": "" + }, + { + "label": "Glaucoma", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "A peripherally acting antimuscarinic (anticholinergic) agent. Rapidly relaxes smooth muscle in the GI and genitourinary tracts. Superb for colicky pain.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **100 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Because it is a quaternary ammonium compound, it does NOT cross the blood-brain barrier, making it completely free of the delirium/sedation seen with central anticholinergics.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Hyoscine butylbromide is a first-line antispasmodic for abdominal and renal colic, but does not cross the blood-brain barrier (no central sedation) and is contraindicated in bowel obstruction.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Tachycardia (blocks vagal tone to the heart).", + "tags": [] + }, + { + "key": "Ocular", + "val": "CRITICAL — Acute angle-closure glaucoma (pupil dilation blocks drainage).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Dry mouth, worsening of constipation/ileus.", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "MODERATE — Urinary retention (especially in BPH).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "GI / Biliary / Renal Colic", + "val": "**PO** 10-20 mg **QID**.", + "tags": [] + }, + { + "key": "Acute Severe Colic", + "val": "**IV** / **IM** 20 mg STAT. May repeat after 30 mins if needed. Max 100 mg/day.", + "tags": [] + }, + { + "key": "Palliative Care (Secretions)", + "val": "**SC** / **IV** 20 mg q4h PRN, or continuous subcutaneous infusion to dry up 'death rattle'.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Buscopan", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (20 mg/1 mL) for **IV**, **IM**, or **SC**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S2 PO). Prescription (S4 Ampoules).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Biliary colic, renal colic, IBS cramping, palliative control of respiratory secretions.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line for acute smooth muscle spasms. Outstanding for drying excessive terminal respiratory secretions.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Untreated narrow-angle glaucoma, mechanical GI obstruction, myasthenia gravis, paralytic ileus, severe tachycardia.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Hyoscine butylbromide pregnancy row should prompt benefit-risk review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive anticholinergic effects with TCAs, antipsychotics, and antihistamines.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Check **HR** before giving **IV**. Do not push IV if HR > 110 bpm as it will induce severe tachycardia.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Hyoscine Confusion", + "val": "Do NOT confuse Hyoscine Butylbromide (Buscopan) with Hyoscine Hydrobromide (Kwells/Scopoderm). Hydrobromide crosses the blood-brain barrier and causes profound sedation/delirium. Butylbromide stays peripheral.", + "tags": [] + }, + { + "key": "The Colic Trick", + "val": "If a patient is writhing in pain from a kidney stone or gallstone, **IV** Buscopan works in 60 seconds to break the spasm. It is often more effective than opioids for pure colic.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive antagonist of muscarinic (M3) receptors in the smooth muscle of the GI, biliary, and urinary tracts. Paralyzes the muscle, stopping the spasm.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours. **IV** 1-5 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "2-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5 hours. Excreted mostly unchanged.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: BUSCOPAN/hyoscine butylbromide Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Anticholinergic — A peripherally acting antimuscarinic (anticholinergic) agent." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg). (Buscopan)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10-20 mg **QID**. Max **100 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "GI / Biliary / Renal Colic: **PO** 10-20 mg **QID**. Acute Severe Colic: **IV** / **IM** 20 mg STAT. May repeat after 30 mins if needed. Max 100 mg/day. Palliative Care (Secretions): **SC** / **IV** 20 mg q4h PRN, or continuous subcutaneous infusion to dry up 'death rattle'." + }, + { + "label": "Best Uses", + "value": "Hyoscine butylbromide is a first-line antispasmodic for abdominal and renal colic, but does not cross the blood-brain barrier (no central sedation) and is contraindicated in bowel obstruction." + }, + { + "label": "Avoid / Cautions", + "value": "Untreated narrow-angle glaucoma, mechanical GI obstruction, myasthenia gravis, paralytic ileus, severe tachycardia. **Pregnancy** Category B2." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Tachycardia (blocks vagal tone to the heart). Ocular: Acute angle-closure glaucoma (pupil dilation blocks drainage). Gastrointestinal: Dry mouth, worsening of constipation/ileus. Genitourinary: Urinary retention (especially in BPH)." + }, + { + "label": "Key Interactions", + "value": "Additive anticholinergic effects with TCAs, antipsychotics, and antihistamines." + }, + { + "label": "Monitoring", + "value": "Check **HR** before giving **IV**. Do not push IV if HR > 110 bpm as it will induce severe tachycardia. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Do NOT confuse Hyoscine Butylbromide (Buscopan) with Hyoscine Hydrobromide (Kwells/Scopoderm). Hydrobromide crosses the blood-brain barrier and causes profound sedation/delirium. Butylbromide stays peripheral." + } + ] + }, + { + "slug": "loperamide", + "name": "Loperamide", + "class": "Antidiarrhoeal", + "subclass": "Peripheral Opioid Agonist", + "category": "Gastrointestinal - IBD & Antidiarrhoeals", + "accent": "#b45309", + "tag": "ANTIDIARRHOEAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "16 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "11 h", + "cls": "", + "flag": "" + }, + { + "label": "Bloody Stool", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Systemic Abs.", + "value": "POOR", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent peripheral opioid receptor agonist. Slows gut motility and increases water reabsorption. The gold standard for non-infectious or traveller's diarrhea.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **16 mg/day** (8 capsules).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never use in severe inflammatory or bloody diarrhea (dysentery), as paralyzing the gut risks toxic megacolon.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Loperamide is the standard antidiarrhoeal for acute non-infectious diarrhoea, but must never be used in bloody/infectious diarrhoea or C. difficile as it can precipitate toxic megacolon.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Severe constipation, abdominal cramping, paralytic ileus. CRITICAL — Toxic megacolon (if used inappropriately in severe colitis).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CRITICAL — At massive supratherapeutic doses (abuse), causes severe **QTc** prolongation and Torsades de Pointes.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Diarrhea", + "val": "**PO** 4 mg STAT, then 2 mg after every unformed stool. Max **16 mg/day**.", + "tags": [] + }, + { + "key": "Chronic Diarrhea (e.g. Stoma)", + "val": "**PO** 2-4 mg **BD** to **QID** (Titrated to stool consistency).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Gastro-Stop, Imodium", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets (2 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S2). PBS available for chronic conditions.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute uncomplicated diarrhea, high-output ileostomies.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line symptomatic relief for high-volume diarrhea once C. diff and severe bacterial infections are ruled out.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Dysentery (fever + bloody diarrhoea), C. difficile/pseudomembranous colitis, acute ulcerative colitis flare, constipation/ileus risk, children < 12 years.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 12 + } + }, + "note": "Loperamide should not be used in children younger than 12 years." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3; use only when clinically appropriate.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Loperamide pregnancy row should prompt benefit-risk review rather than automatic contraindication." + } + }, + { + "key": "Lactation", + "val": "CONTRAINDICATED — Do not use while breastfeeding according to the Australian IMODIUM CMI.", + "tags": [], + "patient": { + "factors": ["lactation"], + "action": "contraindication", + "severity": "danger", + "note": "Australian IMODIUM CMI advises not to use loperamide while breastfeeding." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "MODERATE — P-gp inhibitors (e.g., Verapamil, Ketoconazole) can theoretically push loperamide across the blood-brain barrier, causing opioid sedation, but rare at normal doses.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Cease immediately if abdominal distension occurs. Monitor stool chart.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **U&E** if diarrhea has been profound (hypokalemia).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Dysentery Rule", + "val": "If a patient has a fever and bloody stool (e.g., Salmonella, Shigella, Campylobacter), do NOT give Loperamide. Paralyzing the gut traps the invasive bacteria, allowing them to erode through the bowel wall and cause sepsis or toxic megacolon.", + "tags": [] + }, + { + "key": "The P-gp Pump", + "val": "Loperamide actually *does* cross into the brain, but a pump (P-glycoprotein) instantly ejects it back into the blood. That's why it causes constipation but no opioid 'high' or respiratory depression.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds directly to mu-opioid receptors in the myenteric plexus of the intestinal wall. Inhibits acetylcholine release, decreasing peristalsis and increasing transit time.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "11 hours. Extremely high first-pass metabolism means almost zero drug reaches the systemic circulation or brain.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: IMODIUM/loperamide Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Peripheral Opioid Agonist — Potent peripheral opioid receptor agonist." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets (2 mg). (Gastro-Stop, Imodium)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 4 mg STAT, then 2 mg after every unformed stool. Max **16 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Acute Diarrhea: **PO** 4 mg STAT, then 2 mg after every unformed stool. Max **16 mg/day**. Chronic Diarrhea (e.g. Stoma): **PO** 2-4 mg **BD** to **QID** (Titrated to stool consistency)." + }, + { + "label": "Best Uses", + "value": "Loperamide is the standard antidiarrhoeal for acute non-infectious diarrhoea, but must never be used in bloody/infectious diarrhoea or C. difficile as it can precipitate toxic megacolon." + }, + { + "label": "Avoid / Cautions", + "value": "Dysentery (fever + bloody diarrhea), C. difficile enterocolitis, acute ulcerative colitis flare, children < 12 years. **Pregnancy** Category B3. Minimal systemic absorption makes it generally safe." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe constipation, abdominal cramping, paralytic ileus. CRITICAL — Toxic megacolon (if used inappropriately in severe colitis). Cardiovascular: At massive supratherapeutic doses (abuse), causes severe **QTc** prolongation and Torsades de Pointes." + }, + { + "label": "Key Interactions", + "value": "P-gp inhibitors (e.g., Verapamil, Ketoconazole) can theoretically push loperamide across the blood-brain barrier, causing opioid sedation, but rare at normal doses." + }, + { + "label": "Monitoring", + "value": "Cease immediately if abdominal distension occurs. Monitor stool chart. Check **U&E** if diarrhea has been profound (hypokalemia)." + }, + { + "label": "Clinical Pearl", + "value": "If a patient has a fever and bloody stool (e.g., Salmonella, Shigella, Campylobacter), do NOT give Loperamide. Paralyzing the gut traps the invasive bacteria, allowing them to erode through the bowel wall and cause sepsis or toxic megacolon." + } + ] + }, + { + "slug": "mesalazine", + "name": "Mesalazine", + "class": "Bowel Inflammation", + "subclass": "5-Aminosalicylic Acid", + "category": "Gastrointestinal - IBD & Antidiarrhoeals", + "accent": "#b45309", + "tag": "ANTI-INFLAMMATORY", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "4.8 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1-2 h", + "cls": "", + "flag": "" + }, + { + "label": "Nephrotoxic", + "value": "MONITOR eGFR", + "cls": "warn", + "flag": "" + }, + { + "label": "Site specific", + "value": "pH RELEASE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Locally acting 5-aminosalicylic acid (5-ASA). The cornerstone maintenance therapy for Ulcerative Colitis. Dampens mucosal inflammation directly.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4.8 g/day** (during acute flares).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Different brands release the drug at different pH levels in the gut. They are NOT interchangeable.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Mesalazine is the cornerstone maintenance therapy for ulcerative colitis, but requires regular renal function monitoring and comes in multiple formulations with different release sites.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal", + "val": "HIGH — Interstitial nephritis, nephrotic syndrome, renal impairment (rare but serious 5-ASA toxicity).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "monitor", + "severity": "caution", + "note": "Existing row flags rare serious 5-ASA renal toxicity; highlights when renal context is entered." + } + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea, abdominal pain, rare pancreatitis.", + "tags": [] + }, + { + "key": "Haematological", + "val": "LOW — Blood dyscrasias (agranulocytosis, aplastic anemia).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Ulcerative Colitis (Flare)", + "val": "**PO** 2.4 - 4.8 g/day in divided doses. Often combined with a **PR** enema or suppository.", + "tags": [] + }, + { + "key": "UC Maintenance", + "val": "**PO** 1.2 - 2.4 g/day (Can often be given **OD**).", + "tags": [] + }, + { + "key": "Distal Proctitis", + "val": "**PR** 1 g suppository **OD** at bedtime.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Pentasa (releases in small bowel + colon), Salofalk (releases in colon), Mezavant (releases in colon).", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets/Granules (500 mg, 1 g, 1.2 g). Do NOT crush enteric-coated tablets.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Suppositories (1 g) and Enemas for **PR** administration.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Induction and maintenance of remission in Ulcerative Colitis. Mild Crohn's disease.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line baseline therapy for UC. Highly effective topically.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal impairment, severe hepatic impairment, or severe salicylate/mesalazine allergy.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic", "allergy-nsaid"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Mesalazine is contraindicated/avoided in severe renal or hepatic impairment and severe salicylate/mesalazine allergy." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C, but continuing effective 5-ASA therapy is often clinically important to prevent IBD flares.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Mesalazine pregnancy row should prompt benefit-risk review and IBD flare-prevention consideration rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CAUTION — Concurrent use with other nephrotoxic drugs (NSAIDs) increases the risk of renal failure.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "LOW — Decreases absorption of Digoxin.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and ongoing **U&E** / **eGFR** every 3-6 months to screen for interstitial nephritis. Annual **FBC** and **LFTs**.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor stool frequency/blood to assess clinical efficacy.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Brand Trap", + "val": "If a patient has inflammation strictly in the terminal colon, Salofalk is perfect. If their disease extends up into the small bowel (e.g., Crohn's), Pentasa is required because it releases earlier in the GI tract. Do not swap them blindly on the ward.", + "tags": [] + }, + { + "key": "The Ghost Pill", + "val": "Some brands (like Asacol/Salofalk) leave an intact ghost tablet in the stool. Reassure the patient the drug has been absorbed and they are just passing the outer matrix.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Topical anti-inflammatory action on the gut mucosa. Inhibits cyclooxygenase and lipoxygenase, reducing prostaglandin and leukotriene production. Acts as an antioxidant.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-2 hours (Systemic absorption is low, ~20%. Action is local).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: SALOFALK/PENTASA mesalazine Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "5-Aminosalicylic Acid — Locally acting 5-aminosalicylic acid (5-ASA)." + }, + { + "label": "Route / Formulation", + "value": "Tablets/Granules (500 mg, 1 g, 1.2 g). Do NOT crush enteric-coated tablets. (Pentasa (releases in small bowel + colon), Salofalk (releases in colon), Mezavant (releases in colon).)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 2.4 - 4.8 g/day in divided doses. Often combined with a **PR** enema or suppository. Max **4.8 g/day** (during acute flares)." + }, + { + "label": "Key Indication Doses", + "value": "Ulcerative Colitis (Flare): **PO** 2.4 - 4.8 g/day in divided doses. Often combined with a **PR** enema or suppository. UC Maintenance: **PO** 1.2 - 2.4 g/day (Can often be given **OD**). Distal Proctitis: **PR** 1 g suppository **OD** at bedtime." + }, + { + "label": "Best Uses", + "value": "Mesalazine is the cornerstone maintenance therapy for ulcerative colitis, but requires regular renal function monitoring and comes in multiple formulations with different release sites." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal impairment (**eGFR** < 30), severe salicylate (aspirin) allergy. **Pregnancy** Category C. Generally considered safe and essential to continue during pregnancy to prevent IBD flares." + }, + { + "label": "Key Risks", + "value": "Renal: Interstitial nephritis, nephrotic syndrome (rare but serious complication of all salicylates). Gastrointestinal: Nausea, abdominal pain, rare pancreatitis. Haematological: Blood dyscrasias (agranulocytosis, aplastic anemia)." + }, + { + "label": "Key Interactions", + "value": "Concurrent use with other nephrotoxic drugs (NSAIDs) increases the risk of renal failure. Decreases absorption of Digoxin." + }, + { + "label": "Monitoring", + "value": "Baseline and ongoing **U&E** / **eGFR** every 3-6 months to screen for interstitial nephritis. Annual **FBC** and **LFTs**. Monitor stool frequency/blood to assess clinical efficacy." + }, + { + "label": "Clinical Pearl", + "value": "If a patient has inflammation strictly in the terminal colon, Salofalk is perfect. If their disease extends up into the small bowel (e.g., Crohn's), Pentasa is required because it releases earlier in the GI tract. Do not swap them blindly on the ward." + } + ] + }, + { + "slug": "sulfasalazine", + "name": "Sulfasalazine", + "class": "Bowel Inflammation", + "subclass": "5-Aminosalicylic Acid Prodrug", + "category": "Gastrointestinal - IBD & Antidiarrhoeals", + "accent": "#b45309", + "tag": "ANTI-INFLAMMATORY", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "4 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6-14 h", + "cls": "", + "flag": "" + }, + { + "label": "Sulfa Allergy", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Folate Depletion", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "A prodrug combining 5-ASA (mesalazine) and sulfapyridine. Used for IBD and Rheumatoid Arthritis. Requires colonic bacteria for activation.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 g/day** (given in divided doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The sulfapyridine component causes significant systemic toxicity (rash, marrow suppression). High rates of intolerance compared to pure Mesalazine.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Sulfasalazine is a dual-action DMARD used in ulcerative colitis and rheumatoid arthritis, but causes significant GI intolerance, requires folate supplementation, and can cause blood dyscrasias.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Bone marrow suppression (leukopenia, agranulocytosis), megaloblastic anemia (due to folate inhibition).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "HIGH — Rash, Stevens-Johnson Syndrome (SJS) due to the sulfa moiety.", + "tags": [], + "patient": { + "factors": ["allergy-sulfa"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Genitourinary", + "val": "MODERATE — Reversible oligospermia (reduced sperm count) in males.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Ulcerative Colitis (Flare)", + "val": "**PO** 1-2 g **QID** (Max 4 g/day).", + "tags": [] + }, + { + "key": "Rheumatoid Arthritis", + "val": "Start **PO** 500 mg **OD**, titrate weekly to 1 g **BD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Salazopyrin, Salazopyrin EN", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (500 mg), Enteric-coated tablets (500 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Ulcerative Colitis, Rheumatoid Arthritis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Excellent for UC patients with concurrent inflammatory arthropathy (as the sulfapyridine component treats the joints, while the 5-ASA treats the gut).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Sulfonamide allergy, Aspirin allergy, Porphyria.", + "tags": [], + "patient": { + "factors": ["allergy-sulfa", "allergy-nsaid"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category A, but prescribe high-dose folic acid because sulfasalazine can impair folate absorption.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Sulfasalazine in pregnancy requires folate supplementation and review, not automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Inhibits absorption of Folic Acid (MANDATORY to prescribe concurrent oral folic acid).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "MODERATE — Can enhance the hypoglycemic effect of sulfonylureas (e.g., Gliclazide).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **FBC** and **LFTs** every 2 weeks for the first 3 months, then 3-monthly to catch bone marrow suppression early.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Warn patients to report unexplained sore throat, fever, or rash immediately (signs of agranulocytosis/SJS).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Yellow Warning", + "val": "Sulfasalazine will stain bodily fluids (urine, sweat, tears) a bright yellow-orange color. It can permanently stain contact lenses. Warn the patient!", + "tags": [] + }, + { + "key": "The Antibiotic Trap", + "val": "Because it relies on colonic bacteria to cleave the prodrug, giving a patient broad-spectrum oral antibiotics will kill the gut flora, rendering the Sulfasalazine completely ineffective.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Cleaved by bacterial azoreductases in the colon into sulfapyridine (systemically absorbed, treats joints) and mesalazine (remains in gut, treats colitis).", + "tags": [] + }, + { + "key": "Onset", + "val": "Weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "6-14 hours (Sulfapyridine is acetylated in the liver).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: SALAZOPYRIN/sulfasalazine Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "5-Aminosalicylic Acid Prodrug — A prodrug combining 5-ASA (mesalazine) and sulfapyridine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (500 mg), Enteric-coated tablets (500 mg). (Salazopyrin, Salazopyrin EN)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1-2 g **QID** (Max 4 g/day)." + }, + { + "label": "Key Indication Doses", + "value": "Ulcerative Colitis (Flare): **PO** 1-2 g **QID** (Max 4 g/day). Rheumatoid Arthritis: Start **PO** 500 mg **OD**, titrate weekly to 1 g **BD**." + }, + { + "label": "Best Uses", + "value": "Sulfasalazine is a dual-action DMARD used in ulcerative colitis and rheumatoid arthritis, but causes significant GI intolerance, requires folate supplementation, and can cause blood dyscrasias." + }, + { + "label": "Avoid / Cautions", + "value": "Sulfonamide allergy, Aspirin allergy, Porphyria. **Pregnancy** Category A, but must prescribe high-dose Folic Acid (5 mg/day) as it interferes with folate absorption." + }, + { + "label": "Key Risks", + "value": "Haematological: Bone marrow suppression (leukopenia, agranulocytosis), megaloblastic anemia (due to folate inhibition). Dermatological: Rash, Stevens-Johnson Syndrome (SJS) due to the sulfa moiety. Genitourinary: Reversible oligospermia (reduced sperm count) in males." + }, + { + "label": "Key Interactions", + "value": "Inhibits absorption of Folic Acid (MANDATORY to prescribe concurrent oral folic acid). Can enhance the hypoglycemic effect of sulfonylureas (e.g., Gliclazide)." + }, + { + "label": "Monitoring", + "value": "**FBC** and **LFTs** every 2 weeks for the first 3 months, then 3-monthly to catch bone marrow suppression early. Warn patients to report unexplained sore throat, fever, or rash immediately (signs of agranulocytosis/SJS)." + }, + { + "label": "Clinical Pearl", + "value": "Sulfasalazine will stain bodily fluids (urine, sweat, tears) a bright yellow-orange color. It can permanently stain contact lenses. Warn the patient!" + } + ] + }, + { + "slug": "bisacodyl", + "name": "Bisacodyl", + "class": "Aperient", + "subclass": "Stimulant Laxative", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "STIMULANT", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "6-12 h (PO)", + "cls": "", + "flag": "" + }, + { + "label": "Cramping", + "value": "COMMON", + "cls": "warn", + "flag": "" + }, + { + "label": "Hypokalemia", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent diphenylmethane stimulant laxative. Directly stimulates enteric nerves to cause colonic mass movements. Often used for bowel prep or severe opioid-induced constipation.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day** (oral) or **10 mg** (rectal).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Tablets are enteric-coated to prevent severe gastric irritation. Do not crush, and do not take with antacids or PPIs.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Bisacodyl is a potent stimulant laxative available in oral and rectal forms for acute constipation, but causes abdominal cramps and is not suitable for long-term use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Severe abdominal cramping, griping pain, nausea. Enteric coating degradation causes severe gastric pain.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Dehydration and hypokalemia (with chronic abuse or high bowel-prep doses).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Constipation", + "val": "**PO** 5-10 mg **NOCTE**. OR **PR** 10 mg suppository STAT.", + "tags": [] + }, + { + "key": "Bowel Preparation", + "val": "**PO** 10 mg **OD** for 2 days prior to procedure, often combined with osmotic agents.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dulcolax, Bisalax", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Enteric-coated tablets (5 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Suppositories (10 mg) for **PR** administration.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Bowel preparation for colonoscopy/surgery, acute severe constipation.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly effective 'push' laxative. Usually reserved for when Senna is ineffective or rapid PR action is needed.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Ileus, intestinal obstruction, acute surgical abdomen (e.g., appendicitis).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category A; reserve stimulant laxatives for short-term use when gentler options are inadequate.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Bisacodyl pregnancy row should prompt short-term/use-only-if-needed review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Antacids, Milk, and PPIs (Pantoprazole). These raise gastric pH, causing the enteric coating of Bisacodyl to dissolve in the stomach instead of the colon, leading to severe vomiting and gastric cramps. Separate by 2 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor bowel chart. Cease immediately once bowels have opened to avoid griping and diarrhea.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Suppository Speed", + "val": "Oral bisacodyl takes all night to work. A bisacodyl suppository (**PR**) works in 20 minutes. Use the suppository if the ward needs an immediate result.", + "tags": [] + }, + { + "key": "Not for Daily Use", + "val": "Chronic use causes 'cathartic colon' (loss of normal bowel tone) and dependence. Restrict to short-term acute use.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Contact laxative. Acts directly on the colonic mucosa to stimulate parasympathetic reflexes, increasing peristalsis and fluid secretion.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 6-12 hours. **PR** 15-60 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Minimal systemic absorption (acts locally in gut lumen).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: DULCOLAX/BISALAX bisacodyl Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Stimulant Laxative — Potent diphenylmethane stimulant laxative." + }, + { + "label": "Route / Formulation", + "value": "Enteric-coated tablets (5 mg). (Dulcolax, Bisalax)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5-10 mg **NOCTE**. OR **PR** 10 mg suppository STAT. Max **10 mg/day** (oral) or **10 mg** (rectal)." + }, + { + "label": "Key Indication Doses", + "value": "Severe Constipation: **PO** 5-10 mg **NOCTE**. OR **PR** 10 mg suppository STAT. Bowel Preparation: **PO** 10 mg **OD** for 2 days prior to procedure, often combined with osmotic agents." + }, + { + "label": "Best Uses", + "value": "Bisacodyl is a potent stimulant laxative available in oral and rectal forms for acute constipation, but causes abdominal cramps and is not suitable for long-term use." + }, + { + "label": "Avoid / Cautions", + "value": "Ileus, intestinal obstruction, acute surgical abdomen (e.g., appendicitis). **Pregnancy** Category A, but strong stimulants are generally avoided due to theoretical uterine stimulation risk." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe abdominal cramping, griping pain, nausea. Enteric coating degradation causes severe gastric pain. Metabolic: Dehydration and hypokalemia (with chronic abuse or high bowel-prep doses)." + }, + { + "label": "Key Interactions", + "value": "Antacids, Milk, and PPIs (Pantoprazole). These raise gastric pH, causing the enteric coating of Bisacodyl to dissolve in the stomach instead of the colon, leading to severe vomiting and gastric cramps. Separate by 2 hours." + }, + { + "label": "Monitoring", + "value": "Monitor bowel chart. Cease immediately once bowels have opened to avoid griping and diarrhea." + }, + { + "label": "Clinical Pearl", + "value": "Oral bisacodyl takes all night to work. A bisacodyl suppository (**PR**) works in 20 minutes. Use the suppository if the ward needs an immediate result." + } + ] + }, + { + "slug": "docusate-sodium", + "name": "Docusate sodium", + "class": "Aperient", + "subclass": "Stool Softener", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "SOFTENER", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "480 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "1-3 Days", + "cls": "", + "flag": "" + }, + { + "label": "Stimulation", + "value": "NONE", + "cls": "warn", + "flag": "" + }, + { + "label": "Efficacy", + "value": "LOW", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Anionic surfactant (detergent). Lowers the surface tension of stool, allowing water and fats to mix in, softening the fecal mass. 'Mush without the push'.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **480 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Completely useless as monotherapy for opioid-induced constipation. Must be paired with a stimulant (Senna).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Docusate sodium is a gentle stool softener for patients where straining is contraindicated, but has weak evidence for efficacy and is often insufficient as monotherapy.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "LOW — Mild abdominal cramping, bitter taste (if liquid is used).", + "tags": [] + }, + { + "key": "Systemic", + "val": "LOW — Extremely benign safety profile. Very safe in the elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Constipation", + "val": "**PO** 120 mg once or twice daily; max **480 mg/day** in divided doses.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Often given as 120 mg **BD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Coloxyl, Coloxyl with Senna (combo)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (50 mg, 120 mg). Drops for pediatrics.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "OTC; docusate 50 mg tablets are also listed on the RPBS/PBS item record.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention and treatment of hard, dry stools.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Used when straining is contraindicated (e.g., post-MI, post-hernia repair, hemorrhoids).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Intestinal obstruction.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. Widely used post-partum.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Liquid paraffin (mineral oil laxatives). Docusate increases the systemic absorption of mineral oil, leading to lipoid pneumonia and hepatic granulomas. Never combine them.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Monitor bowel chart. Efficacy is often poor in severe constipation without a stimulant.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Mush/Push Rule", + "val": "Opioids paralyze the gut. Giving Docusate alone to a patient on Oxycodone just creates soft stool sitting in a paralyzed bowel. You MUST add Senna (the push).", + "tags": [] + }, + { + "key": "Prophylaxis Only", + "val": "Docusate is a preventative agent. It is far too slow to treat acute, established impaction.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Surfactant action. Acts as a detergent to facilitate the admixture of fat and water into the stool.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 24-72 hours (Very slow).", + "tags": [] + }, + { + "key": "Half-life", + "val": "Local action in the gut.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: COLOXYL/docusate Australian ARTG, PBS, TGA OTC monograph, and WA Health source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Stool Softener — Anionic surfactant (detergent)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (50 mg, 120 mg). Drops for pediatrics. (Coloxyl, Coloxyl with Senna (combo))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 120 mg once or twice daily; max **480 mg/day** in divided doses. Combination docusate/senna is commonly used for opioid/palliative constipation." + }, + { + "label": "Key Indication Doses", + "value": "Constipation: **PO** 100-200 mg **BD**. Max 500 mg/day. Elderly / Frail: Often given as 120 mg **BD**." + }, + { + "label": "Best Uses", + "value": "Docusate sodium is a gentle stool softener for patients where straining is contraindicated, but has weak evidence for efficacy and is often insufficient as monotherapy." + }, + { + "label": "Avoid / Cautions", + "value": "Intestinal obstruction. **Pregnancy** Category A. Widely used post-partum." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Mild abdominal cramping, bitter taste (if liquid is used). Systemic: Extremely benign safety profile. Very safe in the elderly." + }, + { + "label": "Key Interactions", + "value": "Liquid paraffin (mineral oil laxatives). Docusate increases the systemic absorption of mineral oil, leading to lipoid pneumonia and hepatic granulomas. Never combine them." + }, + { + "label": "Monitoring", + "value": "Monitor bowel chart. Efficacy is often poor in severe constipation without a stimulant." + }, + { + "label": "Clinical Pearl", + "value": "Opioids paralyze the gut. Giving Docusate alone to a patient on Oxycodone just creates soft stool sitting in a paralyzed bowel. You MUST add Senna (the push)." + } + ] + }, + { + "slug": "fortrans-peg", + "name": "Fortrans/PEG", + "class": "Aperient", + "subclass": "Osmotic Bowel Prep", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "BOWEL PREP", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "3-4 Litres", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "1-2 h", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Volume", + "value": "MASSIVE", + "cls": "warn", + "flag": "" + }, + { + "label": "Dehydration", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Massive-volume PEG (Polyethylene Glycol) solution. Used strictly to completely blast the bowel clean prior to a colonoscopy or major bowel surgery.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **3-4 Litres** drunk over a few hours.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Patients often fail the prep because drinking 4 Litres of salty, thick fluid causes severe nausea and vomiting. Clear liquids must be encouraged.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Fortrans/PEG is a high-volume polyethylene glycol solution for bowel preparation before colonoscopy, but is poorly tolerated due to large volume and taste, and carries electrolyte disturbance risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Explosive, continuous watery diarrhea. HIGH — Severe nausea, vomiting, bloating, abdominal cramping.", + "tags": [] + }, + { + "key": "Renal/Metabolic", + "val": "HIGH — Dehydration, acute kidney injury (AKI) if the patient vomits and fails to drink clear fluids during the prep.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Colonoscopy Bowel Prep", + "val": "**PO** Dissolve each sachet in 1 Litre of water. Drink 1 glass (250 mL) every 15 minutes until 3-4 Litres are consumed. (Often split: 2L the night before, 2L the morning of the procedure).", + "tags": [] + }, + { + "key": "Clear Fluid Diet", + "val": "MANDATORY — Patient MUST stop solid food and move to clear fluids (broth, apple juice) 24 hours before the prep begins.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Glycoprep, Fortrans, Colyte", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Massive sachets of powder (PEG + intense electrolytes) to be mixed into litres of water.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Often supplied directly by the endoscopy clinic. OTC available.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Bowel cleansing prior to clinical procedures (colonoscopy, barium enema, colonic surgery).", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "The most effective, though least palatable, method for guaranteeing a perfectly clean colon for a gastroenterologist.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known/suspected bowel obstruction, toxic megacolon, gastric retention/severe gastroparesis.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CAUTION — Risk of dehydration and AKI if vomiting or inadequate clear-fluid intake occurs; check renal function/electrolytes in high-risk patients.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "monitor", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Macrogol bowel preparation in renal impairment should prompt hydration, renal function, and electrolyte monitoring rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Flushes EVERYTHING out. Any oral medication (e.g., blood pressure pills, oral contraceptives) taken within 2-3 hours of the prep will be flushed out completely unabsorbed.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn the patient they will be tied to the toilet for 4-6 hours. They must have easy, immediate access to a bathroom.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **U&E** post-procedure if the patient is elderly and appears confused/lethargic (risk of AKI).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Chill Hack", + "val": "Drinking 4L of warm salty liquid causes vomiting. Instruct the patient to mix the prep early and leave it in the fridge. Drinking it ice cold significantly numbs the taste buds and reduces the nausea.", + "tags": [] + }, + { + "key": "The Yellow Water Target", + "val": "The patient is 'ready' when their diarrhea looks exactly like clear, pale-yellow urine. If it is still brown or cloudy, the endoscopy will fail and they will have to do it all over again another day.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Massive osmotic flush. The PEG acts as a sponge, ensuring the 4 Litres of water stays in the bowel. The electrolytes prevent the massive water volume from disrupting the blood chemistry.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours. Diarrhea begins rapidly and continues for hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Not absorbed. Flushed out.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: GLYCOPREP/FORTRANS macrogol-electrolyte bowel preparation Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Osmotic Bowel Prep — Massive-volume PEG (Polyethylene Glycol) solution." + }, + { + "label": "Route / Formulation", + "value": "Massive sachets of powder (PEG + intense electrolytes) to be mixed into litres of water. (Glycoprep, Fortrans, Colyte)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** Dissolve each sachet in 1 Litre of water. Drink 1 glass (250 mL) every 15 minutes until 3-4 Litres are consumed. (Often split: 2L the night before, 2L the morning of the procedure). Max **3-4 Litres** drunk over a few hours." + }, + { + "label": "Key Indication Doses", + "value": "Colonoscopy Bowel Prep: **PO** Dissolve each sachet in 1 Litre of water. Drink 1 glass (250 mL) every 15 minutes until 3-4 Litres are consumed. (Often split: 2L the night before, 2L the morning of the procedure). Clear Fluid Diet: Patient MUST stop solid food and move to clear fluids (broth, apple juice) 24 hours before the prep begins." + }, + { + "label": "Best Uses", + "value": "Fortrans/PEG is a high-volume polyethylene glycol solution for bowel preparation before colonoscopy, but is poorly tolerated due to large volume and taste, and carries electrolyte disturbance risk." + }, + { + "label": "Avoid / Cautions", + "value": "Known/suspected bowel obstruction, toxic megacolon, gastric retention/severe gastroparesis." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Explosive, continuous watery diarrhea. HIGH — Severe nausea, vomiting, bloating, abdominal cramping. Renal/Metabolic: Dehydration, acute kidney injury (AKI) if the patient vomits and fails to drink clear fluids during the prep." + }, + { + "label": "Key Interactions", + "value": "Flushes EVERYTHING out. Any oral medication (e.g., blood pressure pills, oral contraceptives) taken within 2-3 hours of the prep will be flushed out completely unabsorbed." + }, + { + "label": "Monitoring", + "value": "Warn the patient they will be tied to the toilet for 4-6 hours. They must have easy, immediate access to a bathroom. Check **U&E** post-procedure if the patient is elderly and appears confused/lethargic (risk of AKI)." + }, + { + "label": "Clinical Pearl", + "value": "Drinking 4L of warm salty liquid causes vomiting. Instruct the patient to mix the prep early and leave it in the fridge. Drinking it ice cold significantly numbs the taste buds and reduces the nausea." + } + ] + }, + { + "slug": "glycerol-suppository", + "name": "Glycerol suppository", + "class": "Aperient", + "subclass": "Osmotic/Stimulant Suppository", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "SUPPOSITORY", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Dose", + "value": "1 Supp PR STAT", + "cls": "blue", + "flag": "" + }, + { + "label": "Onset", + "value": "15-30 mins", + "cls": "good", + "flag": "" + }, + { + "label": "Route", + "value": "PR ONLY", + "cls": "purple", + "flag": "" + }, + { + "label": "Systemic Abs.", + "value": "NONE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Locally acting osmotic and mildly irritant suppository. Draws water into the rectum and triggers the defecation reflex. Highly effective for distal impaction.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "1-2 suppositories **PR** as required.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be inserted into the rectum against the bowel wall (not buried in stool) to act effectively.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Glycerol suppository is a simple, safe rectal osmotic laxative for acute constipation, but provides only local effect and is insufficient for chronic or opioid-induced constipation.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "LOW — Mild rectal irritation, burning sensation, tenesmus (feeling of incomplete emptying).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Distal Constipation", + "val": "**PR** 1 suppository (Adult size) inserted rectally. Retain for 15-30 mins if possible before opening bowels.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Glycerin Suppositories", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Rectal suppositories: adult 2.8 g/4 g product and paediatric sizes. Use the age-appropriate product.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute relief of distal (rectal) constipation, bowel retraining in spinal cord injuries.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line physical intervention on the ward when a patient hasn't opened bowels in days and oral agents are too slow.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Rectal bleeding, severe undiagnosed abdominal pain, acute perianal surgery/trauma, or inability to administer rectally without injury.", + "tags": [] + }, + { + "key": "Neutropenia", + "val": "CRITICAL — Do not use in severely neutropenic or thrombocytopenic patients (e.g., post-chemo) due to risk of micro-trauma, sepsis, and bleeding.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "NONE — No significant drug interactions as it acts entirely locally.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor bowel chart for effectiveness. Provide commode or toilet access immediately after administration.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Placement Trick", + "val": "Insert fully into the rectum with gentle technique. If suspected impaction prevents effect, reassess with DRE/clinical review rather than forcing repeated rectal doses.", + "tags": [] + }, + { + "key": "Moisten Before Use", + "val": "Wetting the suppository with a few drops of water before insertion massively improves patient comfort and hastens the osmotic dissolving action.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Hyperosmolar action draws fluid into the rectum, softening the stool mass. Also acts as a mild local irritant to stimulate rectal peristalsis and provides lubrication.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PR** 15-30 minutes.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Not absorbed systemically.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: Glycerol suppository Australian healthdirect/ARTG and SESLHD constipation source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Osmotic/Stimulant Suppository — Locally acting osmotic and mildly irritant suppository." + }, + { + "label": "Route / Formulation", + "value": "Rectal suppositories: adult 2.8 g/4 g product and paediatric sizes. Use the age-appropriate product." + }, + { + "label": "Usual Dose & Max", + "value": "**PR** 1 suppository (Adult size) inserted rectally. Retain for 15-30 mins if possible before opening bowels. 1-2 suppositories **PR** as required." + }, + { + "label": "Best Uses", + "value": "Glycerol suppository is a simple, safe rectal osmotic laxative for acute constipation, but provides only local effect and is insufficient for chronic or opioid-induced constipation." + }, + { + "label": "Avoid / Cautions", + "value": "Rectal bleeding, severe undiagnosed abdominal pain, acute perianal surgery/trauma. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Mild rectal irritation, burning sensation, tenesmus (feeling of incomplete emptying)." + }, + { + "label": "Key Interactions", + "value": "NONE — No significant drug interactions as it acts entirely locally." + }, + { + "label": "Monitoring", + "value": "Monitor bowel chart for effectiveness. Provide commode or toilet access immediately after administration." + }, + { + "label": "Clinical Pearl", + "value": "If the rectum is packed with hard stool, shoving the suppository into the center of the stool mass will do nothing. It MUST be pushed gently against the actual rectal mucosal wall to melt and trigger the reflex." + } + ] + }, + { + "slug": "ispaghula-husk", + "name": "Ispaghula husk", + "class": "Aperient", + "subclass": "Bulk-forming Laxative", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "BULK LAXATIVE", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "4 Sachets/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "2-3 Days", + "cls": "warn", + "flag": "" + }, + { + "label": "Water Req.", + "value": "MANDATORY", + "cls": "good", + "flag": "warn" + }, + { + "label": "Bloating", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "A specific form of psyllium seed husk. Functionally identical to generic Psyllium (Metamucil). Absorbs water to create a bulky, soft stool.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 sachets/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be consumed with a full glass of water to prevent bowel obstruction/choking.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ispaghula husk is a bulk-forming laxative similar to psyllium for constipation and cholesterol lowering, but must be taken with sufficient fluid and can cause bloating initially.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Bloating, flatulence. CRITICAL — Bowel/esophageal obstruction if taken with insufficient water.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Constipation", + "val": "**PO** 1 sachet dissolved in 150 mL of water, **BD** (morning and evening).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Fybogel, Agiofibe", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Effervescent granules in sachets (often orange or lemon flavoured).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Constipation, maintenance of normal bowel function in hemorrhoids/fissures.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Identical to Psyllium. Patient choice usually dictates use based on flavor/texture preferences.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Fecal impaction, mechanical bowel obstruction, difficulty swallowing (dysphagia).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Binds other oral medications. Separate by 2 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure adequate fluid intake and ability to swallow the prepared dose; avoid use where fluid intake or safe swallowing is unreliable.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Immobilised Trap", + "val": "Do not chart bulk-forming laxatives for bed-bound, immobile geriatric patients. Gut motility requires physical movement. Adding bulk without movement causes severe impaction. Use osmotic agents (Movicol) instead.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Swells in water to form a mucilaginous mass, increasing stool volume and triggering peristalsis.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-3 Days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Not absorbed systemically.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: Ispaghula/Fybogel fibre-laxative source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Bulk-forming Laxative — A specific form of psyllium seed husk." + }, + { + "label": "Route / Formulation", + "value": "Effervescent granules in sachets (often orange or lemon flavoured). (Fybogel, Agiofibe)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1 sachet dissolved in 150 mL of water, **BD** (morning and evening). Max **4 sachets/day**." + }, + { + "label": "Best Uses", + "value": "Ispaghula husk is a bulk-forming laxative similar to psyllium for constipation and cholesterol lowering, but must be taken with sufficient fluid and can cause bloating initially." + }, + { + "label": "Avoid / Cautions", + "value": "Fecal impaction, mechanical bowel obstruction, difficulty swallowing (dysphagia). **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Bloating, flatulence. CRITICAL — Bowel/esophageal obstruction if taken with insufficient water." + }, + { + "label": "Key Interactions", + "value": "Binds other oral medications. Separate by 2 hours." + }, + { + "label": "Monitoring", + "value": "Ensure patient fluid intake is adequate throughout the day, not just with the dose." + }, + { + "label": "Clinical Pearl", + "value": "Do not chart bulk-forming laxatives for bed-bound, immobile geriatric patients. Gut motility requires physical movement. Adding bulk without movement causes severe impaction. Use osmotic agents (Movicol) instead." + } + ] + }, + { + "slug": "lactulose", + "name": "Lactulose", + "class": "Aperient", + "subclass": "Osmotic Laxative", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "OSMOTIC", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "45 mL/day (Aperient)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "1-2 Days", + "cls": "", + "flag": "" + }, + { + "label": "Flatulence", + "value": "HIGH", + "cls": "warn", + "flag": "" + }, + { + "label": "Hepatic Enceph.", + "value": "INDICATED", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Synthetic, non-digestible sugar. Acts as a slow osmotic laxative. Crucially, it acts as a bacterial sink for ammonia in patients with liver failure.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **45 mL/day** for constipation. (Doses in hepatic encephalopathy can exceed 90 mL/day to achieve target bowel actions).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Slow onset. Causes massive gas production and bloating. Often poorly tolerated for simple constipation compared to Movicol.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Lactulose is a first-line osmotic laxative for constipation and hepatic encephalopathy, but causes significant bloating and flatulence and takes 24-48 hours to work.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Severe flatulence, bloating, abdominal cramps, explosive diarrhea (if overdosed).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hypernatremia and dehydration (due to free water loss in stool if taken in massive doses for encephalopathy).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Constipation", + "val": "**PO** 15 mL **OD** to **BD**. Max 45 mL/day.", + "tags": [] + }, + { + "key": "Hepatic Encephalopathy", + "val": "**PO** 30-45 mL **TDS-QID**. Titrate to 2-3 soft stools per day.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Actilax, Duphalac", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Extremely sweet, viscous syrup (3.3 g/5 mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hepatic encephalopathy, chronic constipation.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The gold-standard baseline therapy for preventing and treating confusion in liver cirrhosis.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Bowel obstruction, galactosaemia, disaccharidase deficiency, lactose-free/low-galactose diet requirement, or allergy to lactulose/galactose/lactose.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. Not systemically absorbed.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "LOW — Theoretically, oral antibiotics (like Neomycin) can kill the colonic bacteria needed to ferment lactulose, reducing its efficacy, but in practice, they are often used together successfully for encephalopathy.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Strict stool charting. Target for hepatic encephalopathy is exactly 2-3 soft stools per day. If they have 0, they will get confused. If they have 10, they will dehydrate.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Laboratory", + "val": "Monitor **U&E** (sodium) during aggressive therapy.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "CAUTION — Avoid large or excessive doses without review; monitor hydration, electrolytes, and stool frequency, especially when treating encephalopathy.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Large lactulose doses can cause diarrhoea, dehydration, and electrolyte disturbance in older/frail patients." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Diabetes Myth", + "val": "Even though it is a sickly sweet sugar syrup, Lactulose is NOT digested or absorbed by humans. It is entirely safe to give to severe diabetics and will not spike their BSL.", + "tags": [] + }, + { + "key": "Poor Choice for Simple Constipation", + "val": "Because it relies on bacterial fermentation, it causes horrific gas and bloating. For simple ward constipation, Movicol (Macrogol) is vastly superior and better tolerated.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Osmotic effect pulls water into the bowel. Colonic bacteria ferment lactulose into lactic/acetic acid, dropping the bowel pH. This acidic environment traps toxic ammonia (NH3) as non-absorbable ammonium (NH4+), which is then pooped out.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 24-48 hours (Requires bacterial fermentation to work).", + "tags": [] + }, + { + "key": "Half-life", + "val": "Not applicable (Not absorbed into the bloodstream).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: DUPHALAC/lactulose Australian CMI and constipation guideline source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Osmotic Laxative — Synthetic, non-digestible sugar." + }, + { + "label": "Route / Formulation", + "value": "Extremely sweet, viscous syrup (3.3 g/5 mL). (Actilax, Duphalac)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 15 mL **OD** to **BD**. Max 45 mL/day." + }, + { + "label": "Key Indication Doses", + "value": "Constipation: adults usually 15-45 mL daily initially, then 15-30 mL daily maintenance. Hepatic encephalopathy: **PO** 30-45 mL **TDS-QID**, titrated to 2-3 soft stools/day." + }, + { + "label": "Best Uses", + "value": "Lactulose is a first-line osmotic laxative for constipation and hepatic encephalopathy, but causes significant bloating and flatulence and takes 24-48 hours to work." + }, + { + "label": "Avoid / Cautions", + "value": "Bowel obstruction, Galactosemia. **Pregnancy** Category A. Not systemically absorbed." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe flatulence, bloating, abdominal cramps, explosive diarrhea (if overdosed). Metabolic: Hypernatremia and dehydration (due to free water loss in stool if taken in massive doses for encephalopathy)." + }, + { + "label": "Key Interactions", + "value": "Theoretically, oral antibiotics (like Neomycin) can kill the colonic bacteria needed to ferment lactulose, reducing its efficacy, but in practice, they are often used together successfully for encephalopathy." + }, + { + "label": "Monitoring", + "value": "Strict stool charting. Target for hepatic encephalopathy is exactly 2-3 soft stools per day. If they have 0, they will get confused. If they have 10, they will dehydrate. Monitor **U&E** (sodium) during aggressive therapy." + }, + { + "label": "Clinical Pearl", + "value": "Even though it is a sickly sweet sugar syrup, Lactulose is NOT digested or absorbed by humans. It is entirely safe to give to severe diabetics and will not spike their BSL." + } + ] + }, + { + "slug": "movicol-macrogol", + "name": "Movicol/Macrogol", + "class": "Aperient", + "subclass": "Osmotic Laxative", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "OSMOTIC", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "8 sachets/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "1-2 Days", + "cls": "good", + "flag": "" + }, + { + "label": "Electrolytes", + "value": "BALANCED", + "cls": "good", + "flag": "" + }, + { + "label": "Bloating", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Macrogol 3350 (PEG) combined with electrolytes. The absolute gold-standard, safe, highly effective ward laxative. Pulls water into the bowel without causing electrolyte crashes.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **8 sachets/day** (Strictly for breaking faecal impaction over 3 days). Maintenance is 1-3 sachets/day.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be mixed with exactly 125 mL of water per sachet. Mixing it into a tiny shot glass makes it hypertonic, draining the patient's blood of water into their bowel.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Movicol/Macrogol is an osmotic laxative for chronic constipation and faecal impaction with excellent tolerability, but requires adequate fluid intake and high-dose regimens are needed for disimpaction.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Bloating, fullness, nausea (from drinking the salty fluid), mild cramping (much less than Senna).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "SAFE — The electrolyte balance prevents hyponatremia/hypokalemia even with 8 sachets a day.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Chronic Constipation", + "val": "**PO** 1-3 sachets daily in divided doses. Dissolve each in 125 mL of water.", + "tags": [] + }, + { + "key": "Faecal Impaction", + "val": "**PO** 8 sachets daily (dissolved in 1 Litre of water). Drink over 6 hours. Max 3 days.", + "tags": [] + }, + { + "key": "Renal / Heart Failure", + "val": "SAFE — Because it is iso-osmotic (contains electrolytes), it does not cause fluid shifts into or out of the bloodstream.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Movicol, Clearlax", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Sachets of powder (Macrogol 3350 + Sodium/Potassium/Chloride). Salty/Lemon taste.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (PBS). OTC.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Treatment of chronic constipation, resolution of faecal impaction.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The safest and most reliable baseline laxative in hospitals. Superior to Lactulose (less gas) and Docusate (actually works).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Complete mechanical bowel obstruction, toxic megacolon, perforated gut.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1; can be used when clinically appropriate.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Macrogol pregnancy row should prompt standard benefit-risk review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Can speed up transit time, mildly reducing the absorption of other heavily reliant drugs. Separate by 1-2 hours if possible.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Do not allow patients to mix the powder into their morning coffee or juice (unless using Osmolax) as the salts make it taste terrible and ruin the chemistry.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Mixing Trap", + "val": "If you mix a Movicol sachet into 50mL of water instead of 125mL, the solution is hypertonic. It will aggressively suck water *out* of the patient's blood into their bowel to dilute it, dehydrating them. The 125mL ratio is chemically mandatory to keep it iso-osmotic.", + "tags": [] + }, + { + "key": "The Impaction Nuke", + "val": "If a patient hasn't opened their bowels in 8 days, 8 sachets of Movicol drunk over an afternoon is highly effective and avoids the trauma of massive enemas or manual disimpaction.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Macrogol is a large, inert polymer that cannot be absorbed. It binds to water via hydrogen bonds, holding the water in the colon. The added electrolytes ensure that no sodium or potassium is dragged out of the blood into the stool.", + "tags": [] + }, + { + "key": "Onset", + "val": "1-2 Days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Not absorbed. 100% excreted in feces.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: MOVICOL/macrogol Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Osmotic Laxative — Macrogol 3350 (PEG) combined with electrolytes." + }, + { + "label": "Route / Formulation", + "value": "Sachets of powder (Macrogol 3350 + Sodium/Potassium/Chloride). Salty/Lemon taste. (Movicol, Clearlax)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1-3 sachets daily in divided doses. Dissolve each in 125 mL of water. Max **8 sachets/day** (Strictly for breaking faecal impaction over 3 days). Maintenance is 1-3 sachets/day." + }, + { + "label": "Key Indication Doses", + "value": "Chronic Constipation: **PO** 1-3 sachets daily in divided doses. Dissolve each in 125 mL of water. Faecal Impaction: **PO** 8 sachets daily (dissolved in 1 Litre of water). Drink over 6 hours. Max 3 days. Renal / Heart Failure: Because it is iso-osmotic (contains electrolytes), it does not cause fluid shifts into or out of the bloodstream." + }, + { + "label": "Best Uses", + "value": "Movicol/Macrogol is an osmotic laxative for chronic constipation and faecal impaction with excellent tolerability, but requires adequate fluid intake and high-dose regimens are needed for disimpaction." + }, + { + "label": "Avoid / Cautions", + "value": "Complete mechanical bowel obstruction, toxic megacolon, perforated gut. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Bloating, fullness, nausea (from drinking the salty fluid), mild cramping (much less than Senna). Metabolic: The electrolyte balance prevents hyponatremia/hypokalemia even with 8 sachets a day." + }, + { + "label": "Key Interactions", + "value": "Can speed up transit time, mildly reducing the absorption of other heavily reliant drugs. Separate by 1-2 hours if possible." + }, + { + "label": "Monitoring", + "value": "Do not allow patients to mix the powder into their morning coffee or juice (unless using Osmolax) as the salts make it taste terrible and ruin the chemistry." + }, + { + "label": "Clinical Pearl", + "value": "If you mix a Movicol sachet into 50mL of water instead of 125mL, the solution is hypertonic. It will aggressively suck water *out* of the patient's blood into their bowel to dilute it, dehydrating them. The 125mL ratio is chemically mandatory to keep it iso-osmotic." + } + ] + }, + { + "slug": "osmolax", + "name": "Osmolax", + "class": "Aperient", + "subclass": "Osmotic Laxative", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "OSMOTIC", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "3-4 scoops/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "1-2 Days", + "cls": "good", + "flag": "" + }, + { + "label": "Electrolytes", + "value": "NONE", + "cls": "warn", + "flag": "" + }, + { + "label": "Taste", + "value": "TASTELESS", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Macrogol 3350 (PEG) WITHOUT added electrolytes. Acts exactly like Movicol, but is completely tasteless and can be mixed into any hot or cold drink.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **3-4 scoops/day** (Adults).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Provides the same excellent laxative effect as Movicol, massively improving patient compliance because it doesn't taste like salty lemon water.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Osmolax is an unflavoured macrogol osmotic laxative for constipation, but provides no electrolyte replacement unlike Movicol and requires adequate fluid intake.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "MODERATE — Bloating, flatulence, nausea.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Because it lacks the protective electrolytes of Movicol, massive doses *could* theoretically cause minor electrolyte shifts, but this is clinically rare at standard doses.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Constipation (Adults)", + "val": "**PO** 1-2 scoops (17-34g) **OD**. Mix with 200 mL of any hot/cold liquid (water, juice, coffee).", + "tags": [] + }, + { + "key": "Constipation (Paediatrics)", + "val": "Strictly weight-based (e.g., 1 scoop daily for children > 2 years).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "OsmoLax", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tasteless, odorless white powder (Macrogol 3350 pure).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Not Scheduled; healthdirect/PBS data verify PBS availability for listed Osmolax packs.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Treatment of chronic constipation.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly favored in pediatrics or for picky adult/dementia patients who refuse to drink salty Movicol.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Bowel obstruction, perforated gut.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — May reduce transit time of other drugs.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Monitor bowel actions and ensure adequate fluid intake. Each level scoop is mixed with about 240 mL water; use caution where fluid intake is restricted or unsafe.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Compliance Winner", + "val": "For dementia patients who spit out Movicol, stirring a scoop of Osmolax into their morning cup of tea is completely undetectable and guarantees they get their laxative.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Pure PEG 3350. Osmotically holds water in the colon to soften stool and trigger peristalsis.", + "tags": [] + }, + { + "key": "Onset", + "val": "1-2 Days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Not absorbed. Excreted in feces.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: OSMOLAX/macrogol 3350 healthdirect, PBS, and Australian constipation guideline source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Osmotic Laxative — Macrogol 3350 (PEG) WITHOUT added electrolytes." + }, + { + "label": "Route / Formulation", + "value": "Tasteless, odorless white powder (Macrogol 3350 pure). (OsmoLax)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1-2 scoops (17-34g) **OD**. Mix with 200 mL of any hot/cold liquid (water, juice, coffee). Max **3-4 scoops/day** (Adults)." + }, + { + "label": "Key Indication Doses", + "value": "Constipation (Adults): **PO** 1-2 scoops (17-34g) **OD**. Mix with 200 mL of any hot/cold liquid (water, juice, coffee). Constipation (Paediatrics): Strictly weight-based (e.g., 1 scoop daily for children > 2 years)." + }, + { + "label": "Best Uses", + "value": "Osmolax is an unflavoured macrogol osmotic laxative for constipation, but provides no electrolyte replacement unlike Movicol and requires adequate fluid intake." + }, + { + "label": "Avoid / Cautions", + "value": "Bowel obstruction, perforated gut. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Bloating, flatulence, nausea. Metabolic: Because it lacks the protective electrolytes of Movicol, massive doses *could* theoretically cause minor electrolyte shifts, but this is clinically rare at standard doses." + }, + { + "label": "Key Interactions", + "value": "May reduce transit time of other drugs." + }, + { + "label": "Monitoring", + "value": "Monitor bowel actions and fluid tolerance. Each level scoop is mixed with about 240 mL water; use caution with fluid restriction, dysphagia, or thickened-fluid requirements." + }, + { + "label": "Clinical Pearl", + "value": "For dementia patients who spit out Movicol, stirring a scoop of Osmolax into their morning cup of tea is completely undetectable and guarantees they get their laxative." + } + ] + }, + { + "slug": "psyllium", + "name": "Psyllium", + "class": "Aperient", + "subclass": "Bulk-forming Laxative", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "BULK LAXATIVE", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "30 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "2-3 Days", + "cls": "warn", + "flag": "" + }, + { + "label": "Water Req.", + "value": "MANDATORY", + "cls": "good", + "flag": "warn" + }, + { + "label": "Opioids", + "value": "INEFFECTIVE", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Plant-derived soluble fiber (Metamucil). Absorbs water in the gut to create a bulky, soft stool, which stretches the colon wall and stimulates natural peristalsis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **30 g/day** (e.g., 2 teaspoons TDS).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be consumed with a massive glass of water. If taken without water, it forms a solid concrete plug and causes a catastrophic bowel obstruction.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Psyllium is a natural bulk-forming fibre laxative for constipation and IBS, but must be taken with adequate water to avoid bowel obstruction and takes 2-3 days for effect.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Bloating, flatulence, feeling of fullness. CRITICAL — Esophageal or intestinal obstruction/impaction (if swallowed dry or with inadequate fluid).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Chronic Constipation", + "val": "**PO** 1-2 teaspoons (or sachets) mixed in 250 mL of water, 1 to 3 times a day.", + "tags": [] + }, + { + "key": "Diarrhea / IBS (Off-Label)", + "val": "**PO** Can be used with less water to absorb excess liquid in the gut and firm up watery stools.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Metamucil, Mucilax", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Powder (flavoured or smooth texture). Capsules (require massive water intake).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Simple chronic constipation, improving stool consistency in IBS, hemorrhoids.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line baseline dietary supplement for healthy patients. Useless for opioid-induced or severe hospital constipation.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Fecal impaction, mechanical bowel obstruction, dysphagia, bedbound/immobile patients (high risk of impaction).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. Excellent safe option for pregnancy constipation.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Physically binds and traps other oral medications in the gut gel. Must separate Psyllium from ALL other drugs (especially Digoxin/Lithium) by at least 2 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Confirm adequate fluid intake and ability to swallow the prepared dose. Avoid bulk-forming laxatives where fluid intake, swallowing, or mobility is unreliable.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Opioid Trap", + "val": "Never give Psyllium to a patient on Oxycodone. Opioids paralyze the bowel. Giving a paralyzed bowel a massive clump of fiber just creates a giant, immovable brick in the colon. You must use Senna + Movicol.", + "tags": [] + }, + { + "key": "The Drink Fast Rule", + "val": "Tell the patient to stir it and drink it immediately. If they let the glass sit on the table for 10 minutes, it turns into a solid, un-drinkable block of jelly.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Not digested. Absorbs up to 10 times its weight in water, swelling into a gelatinous mass that stretches the colonic mechanoreceptors, triggering normal bowel movements.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-3 Days. (Extremely slow).", + "tags": [] + }, + { + "key": "Half-life", + "val": "Not absorbed systemically. Excreted in feces.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: Psyllium/Metamucil Australian constipation guideline source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Bulk-forming Laxative — Plant-derived soluble fiber (Metamucil)." + }, + { + "label": "Route / Formulation", + "value": "Powder (flavoured or smooth texture). Capsules (require massive water intake). (Metamucil, Mucilax)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1-2 teaspoons (or sachets) mixed in 250 mL of water, 1 to 3 times a day. Max **30 g/day** (e.g., 2 teaspoons TDS)." + }, + { + "label": "Key Indication Doses", + "value": "Chronic Constipation: **PO** 1-2 teaspoons (or sachets) mixed in 250 mL of water, 1 to 3 times a day. Diarrhea / IBS (Off-Label): **PO** Can be used with less water to absorb excess liquid in the gut and firm up watery stools." + }, + { + "label": "Best Uses", + "value": "Psyllium is a natural bulk-forming fibre laxative for constipation and IBS, but must be taken with adequate water to avoid bowel obstruction and takes 2-3 days for effect." + }, + { + "label": "Avoid / Cautions", + "value": "Fecal impaction, mechanical bowel obstruction, dysphagia, bedbound/immobile patients (high risk of impaction). **Pregnancy** Category A. Excellent safe option for pregnancy constipation." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Bloating, flatulence, feeling of fullness. CRITICAL — Esophageal or intestinal obstruction/impaction (if swallowed dry or with inadequate fluid)." + }, + { + "label": "Key Interactions", + "value": "Physically binds and traps other oral medications in the gut gel. Must separate Psyllium from ALL other drugs (especially Digoxin/Lithium) by at least 2 hours." + }, + { + "label": "Monitoring", + "value": "Confirm adequate fluid intake and ability to swallow the prepared dose. Avoid bulk-forming laxatives where fluid intake, swallowing, or mobility is unreliable." + }, + { + "label": "Clinical Pearl", + "value": "Never give Psyllium to a patient on Oxycodone. Opioids paralyze the bowel. Giving a paralyzed bowel a massive clump of fiber just creates a giant, immovable brick in the colon. You must use Senna + Movicol." + } + ] + }, + { + "slug": "senna", + "name": "Senna", + "class": "Aperient", + "subclass": "Stimulant Laxative", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "STIMULANT", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "4 tabs/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "6-12 h", + "cls": "", + "flag": "" + }, + { + "label": "Cramping", + "value": "COMMON", + "cls": "warn", + "flag": "" + }, + { + "label": "Melanosis Coli", + "value": "CHRONIC USE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Plant-based anthraquinone stimulant laxative. Directly irritates the bowel to force peristalsis. The ultimate 'push' laxative.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 tablets/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Indispensable for opioid-induced constipation. Must be given at night so the bowel moves in the morning.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Senna is a cheap and effective stimulant laxative for opioid-induced and simple constipation, but causes abdominal cramping and should not be used long-term due to dependence risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Severe abdominal cramping, griping pain, explosive diarrhea.", + "tags": [] + }, + { + "key": "Other", + "val": "MODERATE — Melanosis coli (benign, harmless black/brown pigmentation of the colon lining seen on endoscopy after chronic use).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hypokalemia (due to chronic diarrhea/abuse).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Constipation", + "val": "**PO** 2-4 tablets **NOCTE**. For opioid-related constipation, docusate/senna combination is commonly started at 2 tablets nocte and reviewed/titrated.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Senokot, Coloxyl with Senna (combo)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (7.5 mg sennosides).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Opioid-induced constipation, acute severe constipation.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Opioids paralyze the gut. You cannot just use a softener; you MUST use a stimulant (Senna) to force the paralyzed bowel to move.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Intestinal obstruction, acute abdominal conditions, inflammatory bowel conditions, or abdominal pain/nausea/vomiting without assessment.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — Seek healthcare advice before use in pregnancy or breastfeeding; avoid prolonged or excessive stimulant-laxative use.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "Senna use in pregnancy or breastfeeding should prompt healthcare advice and avoidance of prolonged/excessive stimulant-laxative use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "LOW — Minimal direct interactions, but chronic diarrhea can deplete potassium, increasing Digoxin toxicity risk.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor bowel chart. Cease once bowels are opening smoothly to prevent griping pain.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Mush and Push", + "val": "Docusate is the 'Mush' (softens stool). Senna is the 'Push' (forces it out). The combination is the gold standard for opioid constipation.", + "tags": [] + }, + { + "key": "The Urine Scare", + "val": "Senna metabolites can harmlessly turn the patient's urine yellow-brown or red. Warn the patient so they don't panic thinking they are bleeding.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Metabolized by gut bacteria into active anthrones, which directly irritate the myenteric plexus of the colon, triggering strong peristaltic contractions.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 6-12 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Locally acting, systemic half-life irrelevant.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: Senna/sennosides Australian OTC monograph and constipation guideline source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Stimulant Laxative — Plant-based anthraquinone stimulant laxative." + }, + { + "label": "Route / Formulation", + "value": "Tablets (7.5 mg sennosides). (Senokot, Coloxyl with Senna (combo))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 2-4 tablets **NOCTE** (often prescribed alongside Docusate as Coloxyl & Senna). Max **4 tablets/day**." + }, + { + "label": "Best Uses", + "value": "Senna is a cheap and effective stimulant laxative for opioid-induced and simple constipation, but causes abdominal cramping and should not be used long-term due to dependence risk." + }, + { + "label": "Avoid / Cautions", + "value": "Intestinal obstruction, undiagnosed severe abdominal pain, inflammatory bowel disease flares. **Pregnancy** Category A, but strong stimulants can theoretically trigger uterine contractions. Osmotics (Lactulose/Movicol) are preferred." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe abdominal cramping, griping pain, explosive diarrhea. Other: Melanosis coli (benign, harmless black/brown pigmentation of the colon lining seen on endoscopy after chronic use). Metabolic: Hypokalemia (due to chronic diarrhea/abuse)." + }, + { + "label": "Key Interactions", + "value": "Minimal direct interactions, but chronic diarrhea can deplete potassium, increasing Digoxin toxicity risk." + }, + { + "label": "Monitoring", + "value": "Monitor bowel chart. Cease once bowels are opening smoothly to prevent griping pain." + }, + { + "label": "Clinical Pearl", + "value": "Docusate is the 'Mush' (softens stool). Senna is the 'Push' (forces it out). The combination is the gold standard for opioid constipation." + } + ] + }, + { + "slug": "sodium-phosphate-enema", + "name": "Sodium phosphate enema", + "class": "Aperient", + "subclass": "Osmotic Enema", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "ENEMA", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "1 Enema/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "2-5 mins", + "cls": "good", + "flag": "" + }, + { + "label": "Phos. Toxicity", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Renal Risk", + "value": "MANDATORY", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly concentrated hyperosmotic saline enema. Extremely effective for rapid distal bowel clearance, but carries significant risk of severe electrolyte derangement.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1 Enema/day** (Typically a single STAT dose).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Can cause fatal hyperphosphatemia and acute phosphate nephropathy in the elderly or those with renal failure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Sodium phosphate enema is a rapid-acting rectal enema for acute constipation and bowel preparation, but carries serious risk of phosphate toxicity especially in elderly and renally impaired patients.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Electrolytes", + "val": "CRITICAL — Hyperphosphatemia, profound hypocalcemia (precipitates tetany/arrhythmias), hypernatremia.", + "tags": [] + }, + { + "key": "Renal", + "val": "CRITICAL — Acute Phosphate Nephropathy (calcium-phosphate crystals precipitate in the kidneys, causing permanent irreversible renal failure).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Rectal trauma, mucosal sloughing.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Faecal Impaction", + "val": "**PR** 133 mL (1 adult enema) inserted rectally. Retain for 2-5 mins.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CAUTION — Avoid routine use in renal impairment. If considered unavoidable, use only with medical review, hydration, and electrolyte monitoring; prefer lower-risk alternatives where suitable.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "monitor", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Sodium phosphate enemas require medical review and electrolyte/renal monitoring in renal impairment; prefer alternatives where suitable." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Fleet Enema", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-packaged rectal liquid (133 mL). Contains dibasic and monobasic sodium phosphate.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Relief of severe acute constipation, bowel clearance prior to sigmoidoscopy.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Used on the ward only when oral agents and simple suppositories have failed.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known/suspected gastrointestinal obstruction or perforation, megacolon, severe dehydration, or use without medical review when renal impairment, heart disease, or electrolyte disturbance is present.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Existing row says use without medical review is unsafe when renal impairment is present." + } + }, + { + "key": "Elderly / Frail", + "val": "HIGH — Greatly increased risk of phosphate toxicity. Microlax is much safer.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — ACE inhibitors, ARBs, NSAIDs, diuretics, calcium channel blockers, and other drugs affecting renal perfusion/electrolytes increase AKI or electrolyte-risk context; avoid unless medically reviewed.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check renal function/electrolyte risk before use in high-risk patients. If no bowel action/return occurs after administration, contact a doctor urgently and consider phosphate, calcium, sodium, potassium, and renal function checks.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Ensure rapid access to a toilet. Do not give to immobile patients without a bedpan ready.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Retention Danger", + "val": "If a Fleet enema goes in and nothing comes out, it is a medical emergency. The hyperosmotic fluid is sitting in the colon absorbing massive amounts of phosphate into the blood. You must manually disimpact or run a tap-water washout to get it out.", + "tags": [] + }, + { + "key": "The Safer Alternative", + "val": "In renal impairment, frailty, heart disease, or electrolyte-risk states, prefer lower-volume alternatives such as Microlax/Micolette when clinically suitable.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Massive hyperosmotic gradient draws huge amounts of water directly from the rectal mucosa into the bowel lumen, liquefying stool and distending the bowel to force an explosive evacuation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PR** 2-5 minutes.", + "tags": [] + }, + { + "key": "Half-life", + "val": "If retained, significant amounts of sodium and phosphate are absorbed across the colonic mucosa into the blood.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: Fleet/sodium phosphate enema Australian CEC/SESLHD and label source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Osmotic Enema — Highly concentrated hyperosmotic saline enema." + }, + { + "label": "Route / Formulation", + "value": "Pre-packaged rectal liquid (133 mL). Contains dibasic and monobasic sodium phosphate. (Fleet Enema)" + }, + { + "label": "Usual Dose & Max", + "value": "**PR** 133 mL (1 adult enema) inserted rectally. Retain for 2-5 mins. Max **1 Enema/day** (Typically a single STAT dose)." + }, + { + "label": "Key Indication Doses", + "value": "Acute Faecal Impaction: **PR** 133 mL (1 adult enema) inserted rectally. Retain for 2-5 mins. Renal Impairment: Avoid entirely if **eGFR** < 45. Use a Microlax (citrate/lauryl sulfoacetate) enema instead." + }, + { + "label": "Best Uses", + "value": "Sodium phosphate enema is a rapid-acting rectal enema for acute constipation and bowel preparation, but carries serious risk of phosphate toxicity especially in elderly and renally impaired patients." + }, + { + "label": "Avoid / Cautions", + "value": "Renal impairment, congestive heart failure, ascites, megacolon, gastrointestinal obstruction." + }, + { + "label": "Key Risks", + "value": "Electrolytes: Hyperphosphatemia, profound hypocalcemia (precipitates tetany/arrhythmias), hypernatremia. Renal: Acute Phosphate Nephropathy (calcium-phosphate crystals precipitate in the kidneys, causing permanent irreversible renal failure). Gastrointestinal: Rectal trauma, mucosal sloughing." + }, + { + "label": "Key Interactions", + "value": "ACEi, ARBs, NSAIDs, Diuretics. These drugs reduce renal perfusion. Combining them with a Fleet enema guarantees acute kidney injury." + }, + { + "label": "Monitoring", + "value": "Check **U&E** and **eGFR** before prescribing. If the enema is given and the patient retains it (does not poop), you must check serum phosphate and calcium immediately. Ensure rapid access to a toilet. Do not give to immobile patients without a bedpan ready." + }, + { + "label": "Clinical Pearl", + "value": "If a Fleet enema goes in and nothing comes out, it is a medical emergency. The hyperosmotic fluid is sitting in the colon absorbing massive amounts of phosphate into the blood. You must manually disimpact or run a tap-water washout to get it out." + } + ] + }, + { + "slug": "sodium-picosulfate", + "name": "Sodium picosulfate", + "class": "Aperient", + "subclass": "Stimulant Laxative", + "category": "Gastrointestinal - Laxatives", + "accent": "#b45309", + "tag": "STIMULANT", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "15 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "6-12 h", + "cls": "", + "flag": "" + }, + { + "label": "Dehydration", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "NOT REQ.", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent prodrug stimulant laxative. Activated by colonic bacteria. Widely used as oral drops for titration on the ward, or in massive doses for colonoscopy bowel prep.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **15 mg/day** (as standard drops). Bowel prep doses are much higher.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly titratable via liquid drops. Essential to maintain oral hydration during use.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Sodium picosulfate is a stimulant laxative primarily used for bowel preparation before procedures, but causes significant electrolyte disturbances and dehydration requiring adequate fluid intake.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Abdominal cramps, diarrhea, nausea.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Water and electrolyte depletion (hypokalemia, hyponatremia) especially with bowel prep doses.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Constipation (Drops)", + "val": "**PO** 5-15 mg (10-30 drops) **NOCTE**.", + "tags": [] + }, + { + "key": "Bowel Preparation (Picoprep)", + "val": "**PO** Dissolve sachets (10 mg) in water, taken exactly as per endoscopy protocol (often split dosing).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dulcolax SP Drops, Picoprep (combo with magnesium citrate)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Oral liquid drops (7.5 mg/mL). Oral powder sachets (bowel prep).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Short-term relief of constipation, bowel clearance prior to procedures.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Liquid drops allow for very fine titration in the elderly compared to fixed-dose Senna tablets.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Bowel obstruction, severe inflammatory bowel disease, toxic megacolon.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "CAUTION — High risk of hypovolaemia and electrolyte disturbance, especially with bowel-prep doses; ensure active fluid intake and monitoring.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Sodium picosulfate in elderly/frail patients requires hydration and electrolyte/volume monitoring rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "LOW — Broad-spectrum antibiotics may theoretically reduce the colonic bacteria needed to activate the drug, but rarely clinically significant.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor fluid input/output strictly if using for bowel prep. High risk of orthostatic hypotension due to fluid loss.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **U&E** if patient becomes confused or lethargic post-bowel prep (hyponatremia).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Drop Titration", + "val": "If 10 drops do nothing, and 20 drops cause explosive diarrhea, you can instruct the patient to use exactly 15 drops. This granularity makes it an excellent choice for tricky chronic constipation.", + "tags": [] + }, + { + "key": "Prep Induced AKI", + "val": "Bowel prep causes massive volume shifts. Always withhold ACEi, ARBs, Diuretics, and NSAIDs on the day of bowel preparation to prevent acute kidney injury.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug. Cleaved by colonic bacteria into the active compound (bis-(p-hydroxyphenyl)-pyridyl-2-methane), which directly stimulates the colonic mucosa.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 6-12 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Local action in colon. Trace systemic absorption is renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: DULCOLAX SP/PICOSALAX sodium picosulfate Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Stimulant Laxative — Potent prodrug stimulant laxative." + }, + { + "label": "Route / Formulation", + "value": "Oral liquid drops (7.5 mg/mL). Oral powder sachets (bowel prep). (Dulcolax SP Drops, Picoprep (combo with magnesium citrate))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5-15 mg (10-30 drops) **NOCTE**. Max **15 mg/day** (as standard drops). Bowel prep doses are much higher." + }, + { + "label": "Key Indication Doses", + "value": "Constipation (Drops): **PO** 5-15 mg (10-30 drops) **NOCTE**. Bowel Preparation (Picoprep): **PO** Dissolve sachets (10 mg) in water, taken exactly as per endoscopy protocol (often split dosing)." + }, + { + "label": "Best Uses", + "value": "Sodium picosulfate is a stimulant laxative primarily used for bowel preparation before procedures, but causes significant electrolyte disturbances and dehydration requiring adequate fluid intake." + }, + { + "label": "Avoid / Cautions", + "value": "Bowel obstruction, severe inflammatory bowel disease, toxic megacolon." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Abdominal cramps, diarrhea, nausea. Metabolic: Water and electrolyte depletion (hypokalemia, hyponatremia) especially with bowel prep doses." + }, + { + "label": "Key Interactions", + "value": "Broad-spectrum antibiotics may theoretically reduce the colonic bacteria needed to activate the drug, but rarely clinically significant." + }, + { + "label": "Monitoring", + "value": "Monitor fluid input/output strictly if using for bowel prep. High risk of orthostatic hypotension due to fluid loss. Check **U&E** if patient becomes confused or lethargic post-bowel prep (hyponatremia)." + }, + { + "label": "Clinical Pearl", + "value": "If 10 drops do nothing, and 20 drops cause explosive diarrhea, you can instruct the patient to use exactly 15 drops. This granularity makes it an excellent choice for tricky chronic constipation." + } + ] + }, + { + "slug": "apixaban", + "name": "Apixaban", + "class": "Anticoagulant", + "subclass": "DOAC", + "category": "Haematology - Anticoagulants & Haemostatics", + "accent": "#0284c7", + "tag": "DOAC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "5 mg BD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12 h", + "cls": "", + "flag": "" + }, + { + "label": "Bleeding Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Monitoring", + "value": "ROUTINE NOT REQ.", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Direct Factor Xa inhibitor. Often preferred for the elderly due to the lowest rate of GI bleeding among the DOACs and lower reliance on renal clearance.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **5 mg BD**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Requires strict **BD** dosing. If the patient is prone to forgetting doses, Rivaroxaban (OD) is a safer option.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Apixaban is the DOAC with the best bleeding profile and is preferred in elderly and renally impaired patients, but requires twice-daily dosing and has limited options for reversal.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Major haemorrhage (Though statistically lower risk of fatal bleeding compared to Warfarin and Rivaroxaban).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Nausea.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Non-Valvular AF", + "val": "**PO** 5 mg **BD**.", + "tags": [] + }, + { + "key": "AF Dose Reduction", + "val": "MANDATORY — Reduce to **2.5 mg BD** if the patient meets TWO of the following: Age ≥ 80, Weight ≤ 60 kg, Creatinine ≥ 133 micromol/L.", + "tags": [] + }, + { + "key": "Acute VTE / DVT / PE", + "val": "**PO** 10 mg **BD** for 7 days, then 5 mg **BD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Eliquis", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (2.5 mg, 5 mg). Taken with or without food.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Stroke prevention in non-valvular AF, treatment and prevention of DVT/PE.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Often the first-line DOAC choice in WA Health for frail, elderly patients due to superior safety profile (ARISTOTLE trial).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Mechanical heart valves, moderate-to-severe mitral stenosis, active bleeding.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CAUTION — Avoid if **eGFR** < 25 mL/min (though specialist use down to eGFR 15 is sometimes endorsed in US guidelines, Australian guidelines recommend caution).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 25 + } + }, + "note": "Avoid apixaban or seek specialist advice at very low eGFR; check renal function before and during treatment." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Strong combined inhibitors of CYP3A4 and P-gp (Ketoconazole, Clarithromycin). Avoid combination.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — NSAIDs, SSRIs.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **U&E** and **eGFR** at baseline to calculate the 'Two of Three' rule. No routine INR/aPTT needed.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor for bleeding.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 2-of-3 Rule", + "val": "Never dose-reduce to 2.5mg BD 'just to be safe'. Unless the patient meets exactly TWO of the three criteria (Age>80, Wt<60, Cr>133) or has severe renal failure, sub-therapeutic dosing significantly increases stroke risk.", + "tags": [] + }, + { + "key": "The Missed Dose", + "val": "Because it is taken BD, a missed dose is dangerous. If missed, take immediately unless it is within 6 hours of the next scheduled dose.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Direct, reversible inhibitor of the active site of Factor Xa.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 3-4 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12 hours (Requires **BD** dosing. Only ~27% renally cleared, making it safer in CKD).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ELIQUIS ARTG/PI, TGA oral anticoagulant safety updates, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "DOAC — Direct Factor Xa inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (2.5 mg, 5 mg). Taken with or without food. (Eliquis)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5 mg **BD**. Max **5 mg BD**." + }, + { + "label": "Key Indication Doses", + "value": "Non-Valvular AF: **PO** 5 mg **BD**. AF Dose Reduction: Reduce to **2.5 mg BD** if the patient meets TWO of the following: Age ≥ 80, Weight ≤ 60 kg, Creatinine ≥ 133 micromol/L. Acute VTE / DVT / PE: **PO** 10 mg **BD** for 7 days, then 5 mg **BD**." + }, + { + "label": "Best Uses", + "value": "Apixaban is the DOAC with the best bleeding profile and is preferred in elderly and renally impaired patients, but requires twice-daily dosing and has limited options for reversal." + }, + { + "label": "Avoid / Cautions", + "value": "Mechanical heart valves, moderate-to-severe mitral stenosis, active bleeding. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Haematological: Major haemorrhage (Though statistically lower risk of fatal bleeding compared to Warfarin and Rivaroxaban). Gastrointestinal: Nausea." + }, + { + "label": "Key Interactions", + "value": "Strong combined inhibitors of CYP3A4 and P-gp (Ketoconazole, Clarithromycin). Avoid combination. NSAIDs, SSRIs." + }, + { + "label": "Monitoring", + "value": "**U&E** and **eGFR** at baseline to calculate the 'Two of Three' rule. No routine INR/aPTT needed. Monitor for bleeding." + }, + { + "label": "Clinical Pearl", + "value": "Never dose-reduce to 2.5mg BD 'just to be safe'. Unless the patient meets exactly TWO of the three criteria (Age>80, Wt<60, Cr>133) or has severe renal failure, sub-therapeutic dosing significantly increases stroke risk." + } + ] + }, + { + "slug": "dabigatran", + "name": "Dabigatran", + "class": "Anticoagulant", + "subclass": "Direct Thrombin Inhibitor", + "category": "Haematology - Anticoagulants & Haemostatics", + "accent": "#0284c7", + "tag": "DOAC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "150 mg BD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12-17 h", + "cls": "", + "flag": "" + }, + { + "label": "Blister Pack", + "value": "MUST REMAIN", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Bleeding Risk", + "value": "HIGH", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Direct Oral Anticoagulant (DOAC). The only DOAC that acts directly on Thrombin (Factor IIa) rather than Factor Xa. Highly effective but has strict storage and renal limitations.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **150 mg BD**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The capsules are extremely moisture-sensitive. If removed from the foil blister and put into a dosette box, they rapidly degrade into a useless paste. The patient will clot.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dabigatran is the only DOAC with a specific reversal agent (idarucizumab) for AF and VTE, but is predominantly renally cleared and contraindicated in severe renal impairment.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Major haemorrhage (especially GI bleeding in the elderly).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Dyspepsia, gastritis (The capsule contains a tartaric acid core to aid absorption, which burns the stomach).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Non-Valvular AF / VTE Treatment", + "val": "**PO** 150 mg **BD**.", + "tags": [] + }, + { + "key": "Elderly (> 75 yrs) / High Bleed Risk", + "val": "MANDATORY — **PO** 110 mg **BD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Avoid entirely if **eGFR** < 30 (Highly renally cleared).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Pradaxa", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (75 mg, 110 mg, 150 mg). Do NOT crush, chew, or open (increases bioavailability by 75%, causing fatal bleeding).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Stroke prevention in non-valvular AF, treatment and prevention of DVT/PE, VTE prophylaxis post-orthopaedic surgery.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly effective alternative to Warfarin. Has a specific, instantaneous reversal agent (Idarucizumab).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Mechanical heart valves, **eGFR** < 30, active bleeding, active GI ulcer.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Dabigatran is strongly renal-cleared; avoid at eGFR < 30 mL/min." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — P-gp inhibitors (e.g., Amiodarone, Verapamil, Clarithromycin). These drastically increase Dabigatran absorption, causing severe bleeding. Dose reduction to 110mg BD is mandatory.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — NSAIDs, SSRIs, Aspirin (Additive bleeding risk).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and 6-monthly **eGFR**. Standard INR/aPTT are completely unreliable to measure efficacy.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Warn the patient not to use a dosette box/pill organizer for this specific drug.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Dyspepsia Trap", + "val": "Because of the tartaric acid core, up to 10% of patients get severe indigestion and stop taking the drug, risking a massive stroke. Taking it with a heavy meal and a large glass of water fixes this.", + "tags": [] + }, + { + "key": "The Instant Antidote", + "val": "If a patient on Dabigatran comes in with a massive intracranial hemorrhage, you can give Idarucizumab (Praxbind) IV. It binds to the Dabigatran in the blood and neutralizes it completely in under 5 minutes.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug. Converted to active dabigatran, which acts as a potent, competitive, and reversible direct inhibitor of Thrombin (Factor IIa), halting the conversion of fibrinogen to fibrin.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12-17 hours (Requires strict **BD** dosing). 80% renally excreted.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - PRADAXA ARTG/PI, TGA dabigatran/oral anticoagulant safety updates, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Direct Thrombin Inhibitor — Direct Oral Anticoagulant (DOAC)." + }, + { + "label": "Route / Formulation", + "value": "Capsules (75 mg, 110 mg, 150 mg). Do NOT crush, chew, or open (increases bioavailability by 75%, causing fatal bleeding). (Pradaxa)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 150 mg **BD**. Max **150 mg BD**." + }, + { + "label": "Key Indication Doses", + "value": "Non-Valvular AF / VTE Treatment: **PO** 150 mg **BD**. Elderly (> 75 yrs) / High Bleed Risk: **PO** 110 mg **BD**. Renal Impairment: Avoid entirely if **eGFR** < 30 (Highly renally cleared)." + }, + { + "label": "Best Uses", + "value": "Dabigatran is the only DOAC with a specific reversal agent (idarucizumab) for AF and VTE, but is predominantly renally cleared and contraindicated in severe renal impairment." + }, + { + "label": "Avoid / Cautions", + "value": "Mechanical heart valves, **eGFR** < 30, active bleeding, active GI ulcer. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Haematological: Major haemorrhage (especially GI bleeding in the elderly). Gastrointestinal: Dyspepsia, gastritis (The capsule contains a tartaric acid core to aid absorption, which burns the stomach)." + }, + { + "label": "Key Interactions", + "value": "P-gp inhibitors (e.g., Amiodarone, Verapamil, Clarithromycin). These drastically increase Dabigatran absorption, causing severe bleeding. Dose reduction to 110mg BD is mandatory. NSAIDs, SSRIs, Aspirin (Additive bleeding risk)." + }, + { + "label": "Monitoring", + "value": "Baseline and 6-monthly **eGFR**. Standard INR/aPTT are completely unreliable to measure efficacy. Warn the patient not to use a dosette box/pill organizer for this specific drug." + }, + { + "label": "Clinical Pearl", + "value": "Because of the tartaric acid core, up to 10% of patients get severe indigestion and stop taking the drug, risking a massive stroke. Taking it with a heavy meal and a large glass of water fixes this." + } + ] + }, + { + "slug": "dalteparin", + "name": "Dalteparin", + "class": "Anticoagulant", + "subclass": "LMWH", + "category": "Haematology - Anticoagulants & Haemostatics", + "accent": "#0284c7", + "tag": "LMWH", + "schedule": "S4", + "stats": [ + { + "label": "Prophylaxis", + "value": "5000 U OD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3-5 h", + "cls": "", + "flag": "" + }, + { + "label": "Bleeding Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Low Molecular Weight Heparin (LMWH). Highly similar to Enoxaparin. Used for VTE prophylaxis and treatment. Dosed in 'Units' rather than 'mg'.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **200 IU/kg** per day (Therapeutic weight-based dosing).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Like Enoxaparin, it relies on the kidneys for clearance. High risk of fatal bleeding if full doses are given in severe CKD.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dalteparin is a low-molecular-weight heparin for VTE prophylaxis and treatment, but requires dose adjustment in renal impairment and anti-Xa monitoring in extremes of weight.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Haemorrhage. HIGH — Heparin-Induced Thrombocytopenia (HIT), though slightly less risk than unfractionated heparin.", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Epidural/Spinal hematoma (can cause permanent paralysis if given too close to an epidural block/removal).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "VTE Prophylaxis (Medical/Surgical)", + "val": "**SC** 5000 IU **OD**.", + "tags": [] + }, + { + "key": "Therapeutic VTE/PE/ACS", + "val": "**SC** 200 IU/kg **OD** OR 100 IU/kg **BD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** < 30, reduce prophylaxis dose to 2500 IU **OD**. For therapeutic dosing, switch to unfractionated heparin or monitor Anti-Xa levels strictly.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Fragmin", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled syringes (2500, 5000, 7500, 10000, 12500, 15000, 18000 IU) for **SC** injection.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "VTE prophylaxis, treatment of DVT/PE, ACS (NSTEMI/STEMI).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Direct alternative to Enoxaparin. Often chosen based on hospital contract/formulary preference.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active major bleeding, history of HIT, planned epidural insertion/removal within 12-24 hours.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category C. (Does not cross placenta, safe and standard in pregnancy).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Dalteparin pregnancy row is an informational prompt, not an automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Other anticoagulants, high-dose Aspirin, NSAIDs (Massive bleeding risk).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Monitor **FBC** (platelets) on days 4-14 to screen for HIT. Check **eGFR**.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine aPTT/INR monitoring is useless. Use Anti-Xa levels for monitoring in obesity/pregnancy.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "monitor", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Epidural Rule", + "val": "Never administer a therapeutic dose of Dalteparin within 24 hours of an epidural insertion or removal. The resultant hematoma will compress the spinal cord and cause paraplegia.", + "tags": [] + }, + { + "key": "The Reversal Limitation", + "val": "If massive bleeding occurs, Protamine Sulfate only partially reverses Dalteparin (~60% effective).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to antithrombin, massively accelerating its inhibition of Factor Xa. Has a higher ratio of Anti-Xa to Anti-IIa activity compared to unfractionated heparin.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** Peak activity at 4 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-5 hours. Renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - FRAGMIN ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "LMWH — Low Molecular Weight Heparin (LMWH)." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled syringes (2500, 5000, 7500, 10000, 12500, 15000, 18000 IU) for **SC** injection. (Fragmin)" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** 5000 IU **OD**. Max **200 IU/kg** per day (Therapeutic weight-based dosing)." + }, + { + "label": "Key Indication Doses", + "value": "VTE Prophylaxis (Medical/Surgical): **SC** 5000 IU **OD**. Therapeutic VTE/PE/ACS: **SC** 200 IU/kg **OD** OR 100 IU/kg **BD**. Renal Impairment: If **eGFR** < 30, reduce prophylaxis dose to 2500 IU **OD**. For therapeutic dosing, switch to unfractionated heparin or monitor Anti-Xa levels strictly." + }, + { + "label": "Best Uses", + "value": "Dalteparin is a low-molecular-weight heparin for VTE prophylaxis and treatment, but requires dose adjustment in renal impairment and anti-Xa monitoring in extremes of weight." + }, + { + "label": "Avoid / Cautions", + "value": "Active major bleeding, history of HIT, planned epidural insertion/removal within 12-24 hours. **Pregnancy** Category C. (Does not cross placenta, safe and standard in pregnancy)." + }, + { + "label": "Key Risks", + "value": "Haematological: Haemorrhage. HIGH — Heparin-Induced Thrombocytopenia (HIT), though slightly less risk than unfractionated heparin. Neurological: Epidural/Spinal hematoma (can cause permanent paralysis if given too close to an epidural block/removal)." + }, + { + "label": "Key Interactions", + "value": "Other anticoagulants, high-dose Aspirin, NSAIDs (Massive bleeding risk)." + }, + { + "label": "Monitoring", + "value": "Monitor **FBC** (platelets) on days 4-14 to screen for HIT. Check **eGFR**. Routine aPTT/INR monitoring is useless. Use Anti-Xa levels for monitoring in obesity/pregnancy." + }, + { + "label": "Clinical Pearl", + "value": "Never administer a therapeutic dose of Dalteparin within 24 hours of an epidural insertion or removal. The resultant hematoma will compress the spinal cord and cause paraplegia." + } + ] + }, + { + "slug": "edoxaban", + "name": "Edoxaban", + "class": "Anticoagulant", + "subclass": "DOAC", + "category": "Haematology - Anticoagulants & Haemostatics", + "accent": "#0284c7", + "tag": "DOAC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "60 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10-14 h", + "cls": "", + "flag": "" + }, + { + "label": "Bleeding Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Freq", + "value": "ONCE DAILY", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Direct Factor Xa inhibitor. The newest DOAC. Offers highly convenient once-daily dosing with less food dependence than Rivaroxaban.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **60 mg OD**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Requires strict dose halving based on a combination of weight, age, renal function, and interacting drugs.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Edoxaban is a once-daily DOAC for AF and VTE with simpler dosing, but paradoxically should not be used in patients with high creatinine clearance (>95 mL/min) due to reduced efficacy.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Major haemorrhage. (Less intracranial bleeding than Warfarin, but carries an inherent risk of GI bleeding).", + "tags": [] + }, + { + "key": "Hepatic", + "val": "LOW — Mild transaminitis.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Non-Valvular AF / VTE Treatment", + "val": "**PO** 60 mg **OD**.", + "tags": [] + }, + { + "key": "Dose Reduction Criteria", + "val": "MANDATORY — Reduce to **30 mg OD** if the patient meets ANY ONE of: Weight ≤ 60 kg, **eGFR** 15-50, or concurrent use of strong P-gp inhibitors (e.g., Cyclosporin, Dronedarone, Erythromycin).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "Avoid entirely if **eGFR** < 15.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lixiana", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (15 mg, 30 mg, 60 mg). Can be taken with or without food.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Stroke prevention in non-valvular AF, treatment and prevention of DVT/PE.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "A highly convenient, once-daily alternative to Apixaban/Rivaroxaban. Non-inferior to Warfarin with significantly less major bleeding (ENGAGE AF-TIMI 48 trial).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Mechanical heart valves, active major bleeding, severe hepatic impairment with coagulopathy.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — P-gp inhibitors (Amiodarone, Verapamil, Quinidine, Macrolides) increase Edoxaban levels. Often mandates a dose reduction to 30 mg.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — NSAIDs, Aspirin, SSRIs (Synergistic bleeding risk).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and routine **eGFR** and **Weight** to ensure the dose remains correct. No routine coagulation monitoring (INR) required.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor for signs of occult bleeding (bruising, dark stools).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Weight Cutoff", + "val": "A 59 kg patient MUST be on 30 mg. A 61 kg patient MUST be on 60 mg. The cutoff is sharp and strict. Always weigh the patient accurately before prescribing.", + "tags": [] + }, + { + "key": "The 'Too Good' Kidneys Trap", + "val": "In clinical trials, Edoxaban was found to be slightly *less* effective than Warfarin at preventing strokes in patients with incredibly good kidneys (eGFR > 95), because they pee the drug out too fast. In these 'super-clearers', consider a different DOAC.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Highly selective, direct, and reversible inhibitor of Factor Xa. Interrupts the coagulation cascade, inhibiting thrombin generation and thrombus development.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10-14 hours. 50% renally excreted, 50% biliary/faecal.", + "tags": [] + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "DOAC — Direct Factor Xa inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (15 mg, 30 mg, 60 mg). Can be taken with or without food. (Lixiana)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 60 mg **OD**. Max **60 mg OD**." + }, + { + "label": "Key Indication Doses", + "value": "Non-Valvular AF / VTE Treatment: **PO** 60 mg **OD**. Dose Reduction Criteria: Reduce to **30 mg OD** if the patient meets ANY ONE of: Weight ≤ 60 kg, **eGFR** 15-50, or concurrent use of strong P-gp inhibitors (e.g., Cyclosporin, Dronedarone, Erythromycin). Renal Impairment: Avoid entirely if **eGFR** < 15." + }, + { + "label": "Best Uses", + "value": "Edoxaban is a once-daily DOAC for AF and VTE with simpler dosing, but paradoxically should not be used in patients with high creatinine clearance (>95 mL/min) due to reduced efficacy." + }, + { + "label": "Avoid / Cautions", + "value": "Mechanical heart valves, active major bleeding, severe hepatic impairment with coagulopathy. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Haematological: Major haemorrhage. (Less intracranial bleeding than Warfarin, but carries an inherent risk of GI bleeding). Hepatic: Mild transaminitis." + }, + { + "label": "Key Interactions", + "value": "P-gp inhibitors (Amiodarone, Verapamil, Quinidine, Macrolides) increase Edoxaban levels. Often mandates a dose reduction to 30 mg. NSAIDs, Aspirin, SSRIs (Synergistic bleeding risk)." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **eGFR** and **Weight** to ensure the dose remains correct. No routine coagulation monitoring (INR) required. Monitor for signs of occult bleeding (bruising, dark stools)." + }, + { + "label": "Clinical Pearl", + "value": "A 59 kg patient MUST be on 30 mg. A 61 kg patient MUST be on 60 mg. The cutoff is sharp and strict. Always weigh the patient accurately before prescribing." + } + ] + }, + { + "slug": "enoxaparin", + "name": "Enoxaparin", + "class": "Anticoagulant", + "subclass": "LMWH", + "category": "Haematology - Anticoagulants & Haemostatics", + "accent": "#0284c7", + "tag": "LMWH", + "schedule": "S4", + "stats": [ + { + "label": "Prophylaxis", + "value": "40 mg SC OD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4-5 h", + "cls": "", + "flag": "" + }, + { + "label": "Bleeding Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "HIT Risk", + "value": "MONITOR PLT", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Low Molecular Weight Heparin (LMWH). The workhorse injectable anticoagulant for DVT prophylaxis on the ward and 'bridging' therapy.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1.5 mg/kg OD** or **1 mg/kg BD** (Therapeutic dose).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Requires aggressive dose reduction in renal impairment, as it is exclusively renally cleared.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Enoxaparin is the standard low-molecular-weight heparin for VTE prophylaxis and treatment, but requires dose adjustment in renal impairment and obesity, and monitoring via anti-Xa levels.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Haemorrhage. HIGH — Heparin-Induced Thrombocytopenia (HIT).", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Epidural/Spinal hematoma (can cause permanent paralysis if given too close to an epidural block/removal).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "LOW — Hyperkalemia (mild aldosterone suppression).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "VTE Prophylaxis (Medical)", + "val": "**SC** 40 mg **OD**.", + "tags": [] + }, + { + "key": "VTE Prophylaxis (Renal)", + "val": "MANDATORY — **SC** 20 mg **OD** if **eGFR** < 30.", + "tags": [] + }, + { + "key": "Therapeutic (VTE/PE/ACS)", + "val": "**SC** 1 mg/kg **BD** OR 1.5 mg/kg **OD**.", + "tags": [] + }, + { + "key": "Therapeutic (Renal)", + "val": "MANDATORY — **SC** 1 mg/kg **OD** if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Clexane", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled syringes for **SC** injection (20 mg, 40 mg, 60 mg, 80 mg, 100 mg, 120 mg, 150 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "VTE prophylaxis, treatment of DVT/PE, ACS (NSTEMI/STEMI bridging).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Universal ward prophylaxis. Used to 'bridge' patients initiating Warfarin.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active bleeding, history of HIT, planned epidural/spinal anaesthesia within 12-24 hours.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "HIGH — Highly toxic if unadjusted in CKD. Dose MUST be reduced if **eGFR** < 30.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Reduce enoxaparin dose and monitor closely in severe renal impairment." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — Drug of choice for anticoagulation in **Pregnancy** (does not cross placenta).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Enoxaparin pregnancy row is an informational prompt, not an automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Other anticoagulants, high-dose Aspirin, NSAIDs.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **U&E/eGFR** (calculate dose). Monitor **FBC** (platelets) on days 4-14 to screen for HIT.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine aPTT monitoring is useless. If monitoring is required (e.g., severe obesity, pregnancy), use Anti-Xa levels.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "monitor", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Epidural Rule", + "val": "Never administer a therapeutic dose of Enoxaparin within 24 hours of an epidural insertion or removal. The resultant hematoma will compress the spinal cord and cause paraplegia.", + "tags": [] + }, + { + "key": "Partial Reversal", + "val": "Unlike unfractionated heparin, Enoxaparin is only partially (~60%) reversed by Protamine Sulfate. Bleeding on Enoxaparin is very difficult to stop.", + "tags": [] + }, + { + "key": "Air Bubble", + "val": "Do not expel the air bubble from the pre-filled syringe before injection. It acts as a plug to ensure the full dose enters the subcutaneous tissue.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to antithrombin III, massively accelerating its inhibition of Factor Xa (and to a lesser extent, Factor IIa/Thrombin).", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 3-5 hours to peak anti-Xa activity.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "4-5 hours. Exclusively renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CLEXANE ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "LMWH — Low Molecular Weight Heparin (LMWH)." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled syringes for **SC** injection (20 mg, 40 mg, 60 mg, 80 mg, 100 mg, 120 mg, 150 mg). (Clexane)" + }, + { + "label": "Usual Dose & Max", + "value": "**SC** 40 mg **OD**. Max **1.5 mg/kg OD** or **1 mg/kg BD** (Therapeutic dose)." + }, + { + "label": "Key Indication Doses", + "value": "VTE Prophylaxis (Medical): **SC** 40 mg **OD**. VTE Prophylaxis (Renal): **SC** 20 mg **OD** if **eGFR** < 30. Therapeutic (VTE/PE/ACS): **SC** 1 mg/kg **BD** OR 1.5 mg/kg **OD**. Therapeutic (Renal): **SC** 1 mg/kg **OD** if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Enoxaparin is the standard low-molecular-weight heparin for VTE prophylaxis and treatment, but requires dose adjustment in renal impairment and obesity, and monitoring via anti-Xa levels." + }, + { + "label": "Avoid / Cautions", + "value": "Active bleeding, history of HIT, planned epidural/spinal anaesthesia within 12-24 hours. Drug of choice for anticoagulation in **Pregnancy** (does not cross placenta)." + }, + { + "label": "Key Risks", + "value": "Haematological: Haemorrhage. HIGH — Heparin-Induced Thrombocytopenia (HIT). Neurological: Epidural/Spinal hematoma (can cause permanent paralysis if given too close to an epidural block/removal). Metabolic: Hyperkalemia (mild aldosterone suppression)." + }, + { + "label": "Key Interactions", + "value": "Other anticoagulants, high-dose Aspirin, NSAIDs." + }, + { + "label": "Monitoring", + "value": "**U&E/eGFR** (calculate dose). Monitor **FBC** (platelets) on days 4-14 to screen for HIT. Routine aPTT monitoring is useless. If monitoring is required (e.g., severe obesity, pregnancy), use Anti-Xa levels." + }, + { + "label": "Clinical Pearl", + "value": "Never administer a therapeutic dose of Enoxaparin within 24 hours of an epidural insertion or removal. The resultant hematoma will compress the spinal cord and cause paraplegia." + } + ] + }, + { + "slug": "heparin-iv-sc", + "name": "Heparin (IV/SC)", + "class": "Anticoagulant", + "subclass": "Unfractionated Heparin", + "category": "Haematology - Anticoagulants & Haemostatics", + "accent": "#0284c7", + "tag": "HEPARIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated to aPTT", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1-2 h", + "cls": "warn", + "flag": "" + }, + { + "label": "HIT Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Reversal", + "value": "PROTAMINE (100%)", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Unfractionated Heparin (UFH). A highly volatile, fast-acting anticoagulant. Requires continuous IV infusion and strict blood monitoring, but uniquely safe in end-stage renal failure.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated dynamically based on nomograms (Targeting specific aPTT levels).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Carries the highest risk of Heparin-Induced Thrombocytopenia (HIT). But unlike Enoxaparin, it is 100% reversible in minutes with Protamine.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Heparin (IV/SC) is the standard parenteral anticoagulant for VTE and ACS with rapid onset and short duration, but requires aPTT monitoring and carries the risk of heparin-induced thrombocytopenia (HIT).", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Haemorrhage. HIGH — Heparin-Induced Thrombocytopenia (HIT). Immune-mediated paradoxical massive clotting and dropping platelets.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hyperkalemia (suppresses aldosterone synthesis).", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "LOW — Osteoporosis (with long-term chronic use > 1 month).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Therapeutic Anticoagulation (ACS / PE / DVT)", + "val": "**IV Infusion** Initial bolus (e.g., 5000 Units), followed by continuous infusion (e.g., 1000-1500 Units/hr). Titrate strictly to **aPTT** every 6 hours.", + "tags": [] + }, + { + "key": "VTE Prophylaxis (Renal Failure)", + "val": "**SC** 5000 Units **BD** or **TDS** (Used specifically when eGFR < 30 and LMWH is contraindicated).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "SAFE — Excreted by macrophages/endothelium, NOT the kidneys. The absolute anticoagulant of choice in severe AKI/CKD.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Heparin Sodium (Various brands)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **SC** injection (e.g., 5000 U/0.2 mL). Vials/Bags for **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply only. S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Treatment of VTE/PE, ACS, cardiopulmonary bypass, dialysis lines, VTE prophylaxis in severe renal failure.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Superseded by Enoxaparin/DOACs for general ward use. Reserved for ICU/Dialysis/Cardiac Surgery where instant 'on/off' control and reversibility is mandatory.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of HIT, active uncontrollable bleeding, severe thrombocytopenia, planned epidural within 4 hours.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category C. Does not cross the placenta. Safe to use.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Other anticoagulants, Aspirin, NSAIDs. Massive bleeding risk.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Strict **aPTT** tracking every 6 hours during IV infusion until stable. Check **FBC** (platelets) daily or every 2nd day to screen for HIT.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Two-nurse check required for all pump adjustments. Heparin errors are notoriously lethal.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The HIT Crisis", + "val": "If a patient on an IV Heparin infusion suddenly develops a DVT or a black, necrotic toe, and their platelet count drops by 50%, they have HIT. The heparin has caused their immune system to turn the drug into a massive pro-clotting weapon. Stop the heparin instantly and call Hematology.", + "tags": [] + }, + { + "key": "The 100% Reversal", + "val": "If a patient on IV Heparin has a massive brain bleed, pushing IV Protamine Sulfate will bind and neutralize the heparin completely in under 5 minutes. (Enoxaparin is only 60% reversed by protamine).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to Antithrombin III, accelerating its inactivation of Thrombin (Factor IIa) and Factor Xa. Prevents fibrin formation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate. **SC** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "2-6 hours (Requires continuous infusion).", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-2 hours. Non-linear, dose-dependent clearance via reticuloendothelial system.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - HEPARIN SODIUM ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Unfractionated Heparin — Unfractionated Heparin (UFH)." + }, + { + "label": "Route / Formulation", + "value": "Ampoules for **SC** injection (e.g., 5000 U/0.2 mL). Vials/Bags for **IV** infusion. (Heparin Sodium (Various brands))" + }, + { + "label": "Usual Dose & Max", + "value": "**IV Infusion** Initial bolus (e.g., 5000 Units), followed by continuous infusion (e.g., 1000-1500 Units/hr). Titrate strictly to **aPTT** every 6 hours. Titrated dynamically based on nomograms (Targeting specific aPTT levels)." + }, + { + "label": "Key Indication Doses", + "value": "Therapeutic Anticoagulation (ACS / PE / DVT): **IV Infusion** Initial bolus (e.g., 5000 Units), followed by continuous infusion (e.g., 1000-1500 Units/hr). Titrate strictly to **aPTT** every 6 hours. VTE Prophylaxis (Renal Failure): **SC** 5000 Units **BD** or **TDS** (Used specifically when eGFR < 30 and LMWH is contraindicated). Renal Impairment: Excreted by macrophages/endothelium, NOT the kidneys. The absolute anticoagulant of choice in severe AKI/CKD." + }, + { + "label": "Best Uses", + "value": "Heparin (IV/SC) is the standard parenteral anticoagulant for VTE and ACS with rapid onset and short duration, but requires aPTT monitoring and carries the risk of heparin-induced thrombocytopenia (HIT)." + }, + { + "label": "Avoid / Cautions", + "value": "History of HIT, active uncontrollable bleeding, severe thrombocytopenia, planned epidural within 4 hours. **Pregnancy** Category C. Does not cross the placenta. Safe to use." + }, + { + "label": "Key Risks", + "value": "Haematological: Haemorrhage. HIGH — Heparin-Induced Thrombocytopenia (HIT). Immune-mediated paradoxical massive clotting and dropping platelets. Metabolic: Hyperkalemia (suppresses aldosterone synthesis). Musculoskeletal: Osteoporosis (with long-term chronic use > 1 month)." + }, + { + "label": "Key Interactions", + "value": "Other anticoagulants, Aspirin, NSAIDs. Massive bleeding risk." + }, + { + "label": "Monitoring", + "value": "Strict **aPTT** tracking every 6 hours during IV infusion until stable. Check **FBC** (platelets) daily or every 2nd day to screen for HIT. Two-nurse check required for all pump adjustments. Heparin errors are notoriously lethal." + }, + { + "label": "Clinical Pearl", + "value": "If a patient on an IV Heparin infusion suddenly develops a DVT or a black, necrotic toe, and their platelet count drops by 50%, they have HIT. The heparin has caused their immune system to turn the drug into a massive pro-clotting weapon. Stop the heparin instantly and call Hematology." + } + ] + }, + { + "slug": "rivaroxaban", + "name": "Rivaroxaban", + "class": "Anticoagulant", + "subclass": "DOAC", + "category": "Haematology - Anticoagulants & Haemostatics", + "accent": "#0284c7", + "tag": "DOAC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg OD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5–13 h", + "cls": "", + "flag": "" + }, + { + "label": "Bleeding Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Food", + "value": "TAKE WITH FOOD", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Direct Oral Anticoagulant (DOAC) inhibiting Factor Xa. Offers the massive convenience of once-daily dosing with no INR monitoring, but requires strict adherence to food instructions.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg OD** (Standard AF/VTE dose).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The 15 mg and 20 mg tablets MUST be taken with a substantial meal. If taken on an empty stomach, absorption drops by 40% and the patient will clot.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Rivaroxaban is a convenient once-daily DOAC for AF and VTE, but has no specific reversal agent as effective as idarucizumab (for Dabigatran) and requires dose adjustment in renal impairment.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Major haemorrhage (GI, intracranial). Slightly higher GI bleeding risk compared to Apixaban.", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Dizziness, headache.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Non-Valvular AF", + "val": "**PO** 20 mg **OD** with evening meal.", + "tags": [] + }, + { + "key": "Acute VTE / DVT / PE", + "val": "**PO** 15 mg **BD** with food for 21 days, then 20 mg **OD** with food.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** 30-49, dose is 15 mg **OD**. Avoid if **eGFR** < 30 (Use warfarin or apixaban depending on exact clearance).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Xarelto", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (2.5 mg, 10 mg, 15 mg, 20 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Stroke prevention in non-valvular AF, treatment and prevention of DVT/PE.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "VTE prophylaxis post orthopaedic surgery.", + "tags": ["PBS"] + }, + { + "key": "Clinical Place", + "val": "Excellent choice for patients who prefer once-daily dosing and have good baseline renal function.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Mechanical heart valves, moderate-to-severe mitral stenosis, active bleeding.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Avoid if **eGFR** < 30 mL/min.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Avoid rivaroxaban at eGFR < 30 mL/min unless specialist direction applies." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. Do not use.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Strong combined inhibitors of CYP3A4 and P-gp (e.g., Ketoconazole, Ritonavir, Clarithromycin) massively increase bleeding risk.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — NSAIDs, SSRIs, Aspirin.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **U&E** and **eGFR** at baseline and annually. Standard coagulation tests (INR/aPTT) are unreliable and should not be used to assess DOAC efficacy.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor for bleeding.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Food Rule", + "val": "The 10mg tablet can be taken with or without food. The 15mg and 20mg tablets MUST be taken in the middle of a large meal. Failure to do so is the #1 cause of 'DOAC failure' and recurrent PE.", + "tags": [] + }, + { + "key": "The Reversal Agent", + "val": "If a catastrophic, life-threatening bleed occurs, the specific reversal agent is Andexanet alfa (Ondexxya), which acts as a decoy receptor to bind the drug.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Highly selective, direct, and reversible inhibitor of Factor Xa. Interrupts both the intrinsic and extrinsic coagulation cascades.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2-4 hours (acts rapidly, no bridging required).", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5-9 hours (young adults), 11-13 hours (elderly). Extensively renally cleared (33% unchanged).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - XARELTO ARTG/PI, TGA oral anticoagulant safety updates, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "DOAC — Direct Oral Anticoagulant (DOAC) inhibiting Factor Xa." + }, + { + "label": "Route / Formulation", + "value": "Tablets (2.5 mg, 10 mg, 15 mg, 20 mg). (Xarelto)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 20 mg **OD** with evening meal. Max **20 mg OD** (Standard AF/VTE dose)." + }, + { + "label": "Key Indication Doses", + "value": "Non-Valvular AF: **PO** 20 mg **OD** with evening meal. Acute VTE / DVT / PE: **PO** 15 mg **BD** with food for 21 days, then 20 mg **OD** with food. Renal Impairment: If **eGFR** 30-49, dose is 15 mg **OD**. Avoid if **eGFR** < 30 (Use warfarin or apixaban depending on exact clearance)." + }, + { + "label": "Best Uses", + "value": "Rivaroxaban is a convenient once-daily DOAC for AF and VTE, but has no specific reversal agent as effective as idarucizumab (for Dabigatran) and requires dose adjustment in renal impairment." + }, + { + "label": "Avoid / Cautions", + "value": "Mechanical heart valves, moderate-to-severe mitral stenosis, active bleeding. **Pregnancy** Category C. Do not use." + }, + { + "label": "Key Risks", + "value": "Haematological: Major haemorrhage (GI, intracranial). Slightly higher GI bleeding risk compared to Apixaban. Neurological: Dizziness, headache." + }, + { + "label": "Key Interactions", + "value": "Strong combined inhibitors of CYP3A4 and P-gp (e.g., Ketoconazole, Ritonavir, Clarithromycin) massively increase bleeding risk. NSAIDs, SSRIs, Aspirin." + }, + { + "label": "Monitoring", + "value": "**U&E** and **eGFR** at baseline and annually. Standard coagulation tests (INR/aPTT) are unreliable and should not be used to assess DOAC efficacy. Monitor for bleeding." + }, + { + "label": "Clinical Pearl", + "value": "The 10mg tablet can be taken with or without food. The 15mg and 20mg tablets MUST be taken in the middle of a large meal. Failure to do so is the #1 cause of 'DOAC failure' and recurrent PE." + } + ] + }, + { + "slug": "tranexamic-acid", + "name": "Tranexamic acid", + "class": "Haemostatic", + "subclass": "Antifibrinolytic", + "category": "Haematology - Anticoagulants & Haemostatics", + "accent": "#0284c7", + "tag": "ANTIFIBRINOLYTIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "4 g/day (PO)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3 h", + "cls": "", + "flag": "" + }, + { + "label": "Seizure Risk", + "value": "HIGH IV DOSE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Clotting", + "value": "PROMOTES", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent antifibrinolytic agent. Works by stopping the body from breaking down existing blood clots. Highly effective for massive trauma, severe menstrual bleeding, and post-partum haemorrhage.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 g/day** (**PO**). Massive IV doses used in trauma (e.g., 1g STAT).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Can cause seizures if given in massive IV boluses. Must be dose-reduced in renal failure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Tranexamic acid is an antifibrinolytic essential for trauma haemorrhage, heavy menstrual bleeding, and surgical bleeding, but must be given within 3 hours of trauma and is contraindicated in active thromboembolic disease.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "MODERATE — Hypotension (if pushed rapidly IV). Theoretical increased risk of VTE (DVT/PE).", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Seizures (Convulsions occur with massive IV doses > 2g, often seen in cardiac surgery).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, diarrhea, vomiting (Very common with high oral doses).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Massive Trauma (CRASH-2 Protocol)", + "val": "**IV** 1 g over 10 mins STAT, followed by 1 g infused over 8 hours. (MUST be given within 3 hours of injury).", + "tags": [] + }, + { + "key": "Heavy Menstrual Bleeding", + "val": "**PO** 1 g **TDS** to **QID** for up to 4 days during menstruation. Max 4 g/day.", + "tags": [] + }, + { + "key": "Dental Extraction (on DOAC/Warfarin)", + "val": "**PO** 1 g **TDS** for 2 days, or as a 5% mouthwash swish and spit.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Cyklokapron, Cyclo-F", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (500 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (1 g/10 mL) for **IV** injection/infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major trauma/bleeding, heavy menstrual bleeding, prevention of bleeding in surgery (orthopaedics, cardiac).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The gold-standard drug to 'stop the bleeding'. Carried by paramedics globally for major trauma.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active intravascular clotting (e.g., active severe DVT/PE or ischemic stroke), subarachnoid hemorrhage (causes cerebral edema/infarction).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "HIGH — Massively accumulates in CKD. Dose must be aggressively reduced if **eGFR** < 50.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 50 + } + }, + "note": "Reduce tranexamic acid dose and monitor closely as renal function declines." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Combined Oral Contraceptive Pill (COCP). Using TXA and estrogen together synergistically increases the risk of a fatal DVT or PE.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — If infusing IV, monitor **BP** to ensure it does not crash.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** prior to prescribing long-term oral courses.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Trauma Window", + "val": "In major trauma, TXA saves lives, but ONLY if given within 3 hours of the injury. If given *after* 3 hours, the CRASH-2 trial showed it paradoxically *increases* mortality due to DIC and microvascular clotting. Time is critical.", + "tags": [] + }, + { + "key": "The Epistaxis Hack", + "val": "If a patient has an unstoppable nosebleed (epistaxis), soaking a cotton ball or gauze in the IV Cyklokapron liquid and packing it into the nose provides intense, localized clot stabilization and halts the bleeding rapidly.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitively blocks the lysine-binding sites on plasminogen. This prevents plasminogen from binding to fibrin and activating into plasmin. Without plasmin, the fibrin clot cannot be dissolved (prevents fibrinolysis).", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate. **PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3 hours. Excreted >90% unchanged in the urine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CYKLOKAPRON/TRANEXAMIC ACID ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Antifibrinolytic — Potent antifibrinolytic agent." + }, + { + "label": "Route / Formulation", + "value": "Tablets (500 mg). (Cyklokapron, Cyclo-F)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 1 g over 10 mins STAT, followed by 1 g infused over 8 hours. (MUST be given within 3 hours of injury). Max **4 g/day** (**PO**). Massive IV doses used in trauma (e.g., 1g STAT)." + }, + { + "label": "Key Indication Doses", + "value": "Massive Trauma (CRASH-2 Protocol): **IV** 1 g over 10 mins STAT, followed by 1 g infused over 8 hours. (MUST be given within 3 hours of injury). Heavy Menstrual Bleeding: **PO** 1 g **TDS** to **QID** for up to 4 days during menstruation. Max 4 g/day. Dental Extraction (on DOAC/Warfarin): **PO** 1 g **TDS** for 2 days, or as a 5% mouthwash swish and spit." + }, + { + "label": "Best Uses", + "value": "Tranexamic acid is an antifibrinolytic essential for trauma haemorrhage, heavy menstrual bleeding, and surgical bleeding, but must be given within 3 hours of trauma and is contraindicated in active thromboembolic disease." + }, + { + "label": "Avoid / Cautions", + "value": "Active intravascular clotting (e.g., active severe DVT/PE or ischemic stroke), subarachnoid hemorrhage (causes cerebral edema/infarction)." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Hypotension (if pushed rapidly IV). Theoretical increased risk of VTE (DVT/PE). Neurological: Seizures (Convulsions occur with massive IV doses > 2g, often seen in cardiac surgery). Gastrointestinal: Nausea, diarrhea, vomiting (Very common with high oral doses)." + }, + { + "label": "Key Interactions", + "value": "Combined Oral Contraceptive Pill (COCP). Using TXA and estrogen together synergistically increases the risk of a fatal DVT or PE." + }, + { + "label": "Monitoring", + "value": "If infusing IV, monitor **BP** to ensure it does not crash. Check **eGFR** prior to prescribing long-term oral courses." + }, + { + "label": "Clinical Pearl", + "value": "In major trauma, TXA saves lives, but ONLY if given within 3 hours of the injury. If given *after* 3 hours, the CRASH-2 trial showed it paradoxically *increases* mortality due to DIC and microvascular clotting. Time is critical." + } + ] + }, + { + "slug": "warfarin-vka", + "name": "Warfarin", + "class": "Anticoagulant", + "subclass": "Vitamin K Antagonist", + "category": "Haematology - Anticoagulants & Haemostatics", + "accent": "#0284c7", + "tag": "VKA", + "schedule": "S4", + "stats": [ + { + "label": "Target Range", + "value": "INR 2.0 - 3.0", + "cls": "accent", + "flag": "accent" + }, + { + "label": "Half-life", + "value": "40 h", + "cls": "", + "flag": "" + }, + { + "label": "Bleeding Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Interactions", + "value": "EXTREME", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The classic Vitamin K Antagonist (VKA). Highly effective oral anticoagulant but universally dreaded due to an excruciatingly narrow therapeutic index, massive dietary restrictions, and lethal drug interactions.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated strictly via INR blood testing.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The ONLY approved oral anticoagulant for patients with Mechanical Heart Valves or severe Mitral Stenosis. DOACs will fail and cause fatal valve thrombosis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Warfarin is the only oral anticoagulant for mechanical heart valves, but demands rigorous INR monitoring and has extensive drug/food interactions.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Major haemorrhage, fatal intracranial bleeding (especially if INR > 4.0).", + "tags": [] + }, + { + "key": "Tissue", + "val": "CRITICAL — Warfarin-induced skin necrosis (rare, paradoxical massive blood clotting in the skin microvasculature on days 3-8 of therapy, due to rapid depletion of Protein C before Factor II).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "LOW — Calciphylaxis (with chronic long-term use in CKD).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Anticoagulation", + "val": "Start **PO** 3-5 mg **OD** (strictly taken at 4 PM to align with morning blood tests). Maintenance dose titrated to target **INR** (usually 2.0 - 3.0 for AF/DVT, or 2.5 - 3.5 for Mechanical Valves).", + "tags": [] + }, + { + "key": "Reversal", + "val": "MANDATORY — Minor bleeding/High INR: Oral/IV Vitamin K. Major life-threatening bleeding: IV Prothrombinex-VF + IV Vitamin K.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Coumadin, Marevan", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (1, 2, 3, 5 mg). Coumadin and Marevan are NOT bioequivalent and must NEVER be swapped by the pharmacist without strict INR monitoring.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Mechanical heart valves, moderate/severe mitral stenosis, VTE/PE, AF stroke prevention (if DOACs unsuitable).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Superseded by DOACs (Apixaban/Rivaroxaban) for standard AF and DVT due to convenience, but retains absolute monopoly over mechanical valves.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active bleeding, severe uncompliant patient, lack of access to regular INR blood testing.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Highly teratogenic (Fetal Warfarin Syndrome - bone/cartilage defects, fatal fetal bleeding). Must switch to Heparin.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — **CYP2C9** Inhibitors (Fluconazole, Metronidazole, Amiodarone, Bactrim). These will massively spike Warfarin levels, shooting the INR to 8+ and causing fatal bleeding. Dose must be halved preemptively.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CRITICAL — **CYP2C9** Inducers (Carbamazepine, Rifampicin, St John's Wort). These destroy Warfarin, dropping the INR to 1.0 and causing massive strokes.", + "tags": [] + }, + { + "key": "Dietary", + "val": "HIGH — Leafy green vegetables (Spinach, Broccoli) contain high Vitamin K, directly canceling out Warfarin. Patients must maintain a consistent, unchanging diet.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Strict, lifelong **INR** monitoring (International Normalized Ratio). Usually every 1-4 weeks once stable.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Counsel patients on falls risk. A minor head bump in an elderly patient on Warfarin can cause a slow, fatal subdural hematoma.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Bridging Rule", + "val": "Because Warfarin depletes Protein C (an anti-clotting factor) faster than it depletes the actual clotting factors, it makes the patient hyper-coagulable for the first 3 days. You MUST 'bridge' them with an injectable blood thinner (like Enoxaparin or Heparin) for the first 5 days until the INR hits 2.0, or they will clot.", + "tags": [] + }, + { + "key": "The Brand Loyalty", + "val": "Coumadin and Marevan are made using different crystalline structures. A 5mg dose of Coumadin absorbs differently than a 5mg dose of Marevan. If a patient swaps brands, their INR will completely destabilize. Pick one and stick to it for life.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits Vitamin K Epoxide Reductase (VKORC1). Stops the liver from recycling Vitamin K, halting the synthesis of clotting factors II, VII, IX, X, and Proteins C and S.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. (Takes 4-5 days to deplete existing clotting factors).", + "tags": [] + }, + { + "key": "Half-life", + "val": "40 hours. Extensively metabolised by CYP2C9.", + "tags": [] + } + ] + }, + { + "title": "Special Populations", + "type": "spec", + "rows": [ + { + "key": "Elderly / Frail", + "val": "HIGH — Dramatically increased sensitivity to Warfarin anticoagulant effects. Start at 1-2 mg **OD** and titrate to a lower **INR** target (2.0-2.5). Risk of fatal intracranial haemorrhage from trivial falls is significantly elevated.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Monitor **INR** more frequently as renal function declines. The active S-warfarin isomer clearance is altered. Any infection causing dehydration can cause an **INR** spike.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CRITICAL — **Pregnancy** Category D. Warfarin embryopathy (nasal hypoplasia, limb defects) in first trimester. CNS anomalies and fetal haemorrhage at any stage. Must switch to LMWH (Enoxaparin) during pregnancy. Continue LMWH peripartum.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Paediatric", + "val": "MANDATORY — Paediatric dosing is highly variable and weight-based. Always use a dedicated paediatric anticoagulation service. Target INR range differs by indication.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - MAREVAN/COUMADIN ARTG/PI, TGA oral anticoagulant safety update, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Vitamin K Antagonist — The classic Vitamin K Antagonist (VKA)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (1, 2, 3, 5 mg). Coumadin and Marevan are NOT bioequivalent and must NEVER be swapped by the pharmacist without strict INR monitoring. (Coumadin, Marevan)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 3-5 mg **OD** (strictly taken at 4 PM to align with morning blood tests). Maintenance dose titrated to target **INR** (usually 2.0 - 3.0 for AF/DVT, or 2.5 - 3.5 for Mechanical Valves). Titrated strictly via INR blood testing." + }, + { + "label": "Key Indication Doses", + "value": "Anticoagulation: Start **PO** 3-5 mg **OD** (strictly taken at 4 PM to align with morning blood tests). Maintenance dose titrated to target **INR** (usually 2.0 - 3.0 for AF/DVT, or 2.5 - 3.5 for Mechanical Valves). Reversal: Minor bleeding/High INR: Oral/IV Vitamin K. Major life-threatening bleeding: IV Prothrombinex-VF + IV Vitamin K." + }, + { + "label": "Best Uses", + "value": "Warfarin is the only oral anticoagulant for mechanical heart valves, but demands rigorous INR monitoring and has extensive drug/food interactions." + }, + { + "label": "Avoid / Cautions", + "value": "Active bleeding, severe uncompliant patient, lack of access to regular INR blood testing. **Pregnancy** Category D. Highly teratogenic (Fetal Warfarin Syndrome - bone/cartilage defects, fatal fetal bleeding). Must switch to Heparin." + }, + { + "label": "Key Risks", + "value": "Haematological: Major haemorrhage, fatal intracranial bleeding (especially if INR > 4.0). Tissue: Warfarin-induced skin necrosis (rare, paradoxical massive blood clotting in the skin microvasculature on days 3-8 of therapy, due to rapid depletion of Protein C before Factor II). Metabolic: Calciphylaxis (with chronic long-term use in CKD)." + }, + { + "label": "Key Interactions", + "value": "**CYP2C9** Inhibitors (Fluconazole, Metronidazole, Amiodarone, Bactrim). These will massively spike Warfarin levels, shooting the INR to 8+ and causing fatal bleeding. Dose must be halved preemptively. **CYP2C9** Inducers (Carbamazepine, Rifampicin, St John's Wort). These destroy Warfarin, dropping the INR to 1.0 and causing massive strokes. Leafy green vegetables (Spinach, Broccoli) contain high Vitamin K, directly canceling out Warfarin. Patients must maintain a consistent, unchanging diet." + }, + { + "label": "Monitoring", + "value": "Strict, lifelong **INR** monitoring (International Normalized Ratio). Usually every 1-4 weeks once stable. Counsel patients on falls risk. A minor head bump in an elderly patient on Warfarin can cause a slow, fatal subdural hematoma." + }, + { + "label": "Clinical Pearl", + "value": "Because Warfarin depletes Protein C (an anti-clotting factor) faster than it depletes the actual clotting factors, it makes the patient hyper-coagulable for the first 3 days. You MUST 'bridge' them with an injectable blood thinner (like Enoxaparin or Heparin) for the first 5 days until the INR hits 2.0, or they will clot." + } + ] + }, + { + "slug": "warfarin-anticoagulant", + "name": "Warfarin", + "class": "Anticoagulant", + "subclass": "Vitamin K Antagonist", + "category": "Haematology - Anticoagulants & Haemostatics", + "accent": "#0284c7", + "tag": "ANTICOAGULANT", + "schedule": "S4", + "stats": [ + { + "label": "Target INR", + "value": "2.0 - 3.0", + "cls": "accent", + "flag": "accent" + }, + { + "label": "Half-life", + "value": "40 h", + "cls": "", + "flag": "" + }, + { + "label": "Bleeding Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Interactions", + "value": "VERY HIGH", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The original oral anticoagulant. A Vitamin K antagonist with an extremely narrow therapeutic window, volatile kinetics, and hundreds of drug interactions.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated entirely based on INR results.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The only oral anticoagulant approved for mechanical heart valves or moderate-to-severe mitral stenosis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Warfarin is the only oral anticoagulant for mechanical heart valves and valvular AF, but requires meticulous INR monitoring and has extensive drug and dietary interactions.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Fatal haemorrhage (intracranial, GI).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "HIGH — Warfarin-induced skin necrosis (rare, occurs in the first few days due to rapid depletion of Protein C, causing paradoxical micro-clotting).", + "tags": [] + }, + { + "key": "Other", + "val": "LOW — Purple toe syndrome.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Initiation", + "val": "Start **PO** 5 mg **OD** (at 16:00). Check INR daily. Adjust dose using a validated nomogram.", + "tags": [] + }, + { + "key": "Maintenance", + "val": "**PO** 1-10 mg **OD**. Guided entirely by INR (Target 2.0-3.0 for most, 2.5-3.5 for mechanical valves).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Start at 2.5 mg or lower. Extremely sensitive.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Coumadin, Marevan (Do NOT interchange brands without intense INR monitoring).", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (1 mg, 2 mg, 3 mg, 5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Mechanical heart valves, AF with valvular disease, VTE/PE.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Superseded by DOACs for standard AF/VTE, but remains absolute mandatory therapy for metallic heart valves and antiphospholipid syndrome.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — High fall risk, active bleeding, severe non-compliance.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Teratogenic (fetal warfarin syndrome). Must switch to LMWH.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Hepatic Impairment", + "val": "HIGH — Coagulation factors are made in the liver. Liver failure exponentially increases warfarin sensitivity.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — **CYP2C9** inhibitors (Amiodarone, Metronidazole, Fluconazole, Bactrim) massively spike INR and cause bleeding. You MUST halve the warfarin dose if starting these.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — NSAIDs, Aspirin, SSRIs (increase bleeding risk without changing INR).", + "tags": [] + }, + { + "key": "Dietary", + "val": "HIGH — Leafy greens (broccoli, spinach) contain high Vitamin K and reverse the drug's effect. Diet must be consistent.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Strict, lifelong **INR** monitoring.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Assess for bruising, bleeding gums, melaena, haematuria.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Reversal Agent", + "val": "If a patient on Warfarin has a life-threatening bleed, Vitamin K IV alone is too slow. You MUST give Prothrombinex-VF (Factor II, IX, X) immediately alongside Vitamin K to restore clotting factors.", + "tags": [] + }, + { + "key": "The Protein C Paradox", + "val": "Warfarin initially depletes Protein C (a natural anticoagulant) faster than it depletes clotting factors. This creates a hypercoagulable state for 48 hours. Patients must be 'bridged' with Enoxaparin to prevent massive clotting during initiation.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits Vitamin K Epoxide Reductase (VKORC1). Halts the hepatic synthesis of Vitamin K-dependent clotting factors (II, VII, IX, X) and Proteins C & S.", + "tags": [] + }, + { + "key": "Onset", + "val": "36-72 hours (Requires a bridging anticoagulant like Heparin/Enoxaparin initially).", + "tags": [] + }, + { + "key": "Duration", + "val": "2-5 Days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "40 hours.", + "tags": [] + } + ] + }, + { + "title": "Special Populations", + "type": "spec", + "rows": [ + { + "key": "Elderly / Frail", + "val": "HIGH — Dramatically increased sensitivity to Warfarin anticoagulant effects. Start at 1-2 mg **OD** and titrate to a lower **INR** target (2.0-2.5). Risk of fatal intracranial haemorrhage from trivial falls is significantly elevated.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Monitor **INR** more frequently as renal function declines. The active S-warfarin isomer clearance is altered. Any infection causing dehydration can cause an **INR** spike.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CRITICAL — **Pregnancy** Category D. Warfarin embryopathy (nasal hypoplasia, limb defects) in first trimester. CNS anomalies and fetal haemorrhage at any stage. Must switch to LMWH (Enoxaparin) during pregnancy. Continue LMWH peripartum.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Paediatric", + "val": "MANDATORY — Paediatric dosing is highly variable and weight-based. Always use a dedicated paediatric anticoagulation service. Target INR range differs by indication.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - MAREVAN/COUMADIN ARTG/PI, TGA oral anticoagulant safety update, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Vitamin K Antagonist — The original oral anticoagulant." + }, + { + "label": "Route / Formulation", + "value": "Tablets (1 mg, 2 mg, 3 mg, 5 mg). (Coumadin, Marevan (Do NOT interchange brands without intense INR monitoring).)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 5 mg **OD** (at 16:00). Check INR daily. Adjust dose using a validated nomogram. Titrated entirely based on INR results." + }, + { + "label": "Key Indication Doses", + "value": "Initiation: Start **PO** 5 mg **OD** (at 16:00). Check INR daily. Adjust dose using a validated nomogram. Maintenance: **PO** 1-10 mg **OD**. Guided entirely by INR (Target 2.0-3.0 for most, 2.5-3.5 for mechanical valves). Elderly / Frail: Start at 2.5 mg or lower. Extremely sensitive." + }, + { + "label": "Best Uses", + "value": "Warfarin is the only oral anticoagulant for mechanical heart valves and valvular AF, but requires meticulous INR monitoring and has extensive drug and dietary interactions." + }, + { + "label": "Avoid / Cautions", + "value": "High fall risk, active bleeding, severe non-compliance. **Pregnancy** Category D. Teratogenic (fetal warfarin syndrome). Must switch to LMWH." + }, + { + "label": "Key Risks", + "value": "Haematological: Fatal haemorrhage (intracranial, GI). Dermatological: Warfarin-induced skin necrosis (rare, occurs in the first few days due to rapid depletion of Protein C, causing paradoxical micro-clotting). Other: Purple toe syndrome." + }, + { + "label": "Key Interactions", + "value": "**CYP2C9** inhibitors (Amiodarone, Metronidazole, Fluconazole, Bactrim) massively spike INR and cause bleeding. You MUST halve the warfarin dose if starting these. NSAIDs, Aspirin, SSRIs (increase bleeding risk without changing INR). Leafy greens (broccoli, spinach) contain high Vitamin K and reverse the drug's effect. Diet must be consistent." + }, + { + "label": "Monitoring", + "value": "Strict, lifelong **INR** monitoring. Assess for bruising, bleeding gums, melaena, haematuria." + }, + { + "label": "Clinical Pearl", + "value": "If a patient on Warfarin has a life-threatening bleed, Vitamin K IV alone is too slow. You MUST give Prothrombinex-VF (Factor II, IX, X) immediately alongside Vitamin K to restore clotting factors." + } + ] + }, + { + "slug": "aspirin", + "name": "Aspirin", + "class": "Anticoagulant", + "subclass": "Antiplatelet / NSAID", + "category": "Haematology - Antiplatelets", + "accent": "#0284c7", + "tag": "ANTIPLATELET", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Dose", + "value": "100 mg OD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "15 mins", + "cls": "warn", + "flag": "" + }, + { + "label": "Bleeding Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Gastroprotection", + "value": "CONSIDER", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Irreversible COX-1 inhibitor. The foundational antiplatelet for all forms of atherosclerotic cardiovascular disease.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **150 mg/day** (For cardiac use). Doses up to 4g/day are historically used for pain/rheumatology but are obsolete due to toxicity.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Causes permanent platelet inhibition. Platelets take 7-10 days to regenerate, making surgery planning crucial.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Aspirin is essential for secondary prevention of cardiovascular and cerebrovascular events, but is no longer recommended for primary prevention due to bleeding risk outweighing benefit.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "HIGH — Bleeding, bruising.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Peptic ulcer disease, GI haemorrhage, dyspepsia.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "MODERATE — Aspirin-exacerbated respiratory disease (AERD) / Bronchospasm in sensitive asthmatics.", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute ACS / STEMI", + "val": "**PO** 300 mg STAT (chewed or dissolved).", + "tags": [] + }, + { + "key": "Secondary Prevention (MI/CVA)", + "val": "**PO** 100 mg **OD**.", + "tags": [] + }, + { + "key": "Analgesia (Obsolete)", + "val": "**PO** 300-900 mg q4-6h (Do not use on the ward. Use Paracetamol/Ibuprofen).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Astrix, Cartia, Cardiprin, Aspro", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Enteric-coated tablets (100 mg), Dispersible tablets (300 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC) / Unrestricted PBS.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute coronary syndromes, secondary prevention of MI/CVA/TIA.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Pre-eclampsia prophylaxis in high-risk pregnancy.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Mandatory for all patients with established coronary or cerebrovascular disease unless strictly contraindicated.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active bleeding (e.g., active peptic ulcer), hemophilia, children < 16 years (Reye's syndrome risk).", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — Avoid high doses in 3rd trimester. Low dose (150mg) is safe and used for pre-eclampsia prophylaxis.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "CAUTION — High doses exacerbate renal failure; low-dose (100mg) is generally safe.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Other antiplatelets (Clopidogrel), DOACs, Warfarin, NSAIDs. Massively increases fatal bleed risk. (Dual Antiplatelet Therapy (DAPT) is strictly for stenting/ACS and usually limited to 1-12 months).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CAUTION — Ibuprofen competitively binds COX-1, physically blocking Aspirin from accessing the receptor. Take aspirin 2 hours before ibuprofen.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for melaena (black tarry stool) or hematemesis.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **FBC** to monitor for slow, silent GI bleeds (dropping hemoglobin).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Chew Rule", + "val": "In an acute heart attack, an enteric-coated 100mg tablet will take too long to dissolve in the stomach. Give a 300mg dispersible tablet, or force the patient to chew the enteric-coated pill to ensure rapid mucosal absorption.", + "tags": [] + }, + { + "key": "PPI Cover", + "val": "Any elderly patient placed on Aspirin should be strongly considered for a prophylactic PPI (Pantoprazole) to prevent fatal GI bleeding.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Irreversibly acetylates Cyclooxygenase-1 (COX-1), blocking Thromboxane A2 production for the entire 7-10 day lifespan of the platelet.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins (faster if chewed).", + "tags": [] + }, + { + "key": "Duration", + "val": "7-10 Days (Antiplatelet effect).", + "tags": [] + }, + { + "key": "Half-life", + "val": "15-20 minutes (Rapidly converted to salicylic acid).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CARTIA/aspirin ARTG, CMI, TGA OTC aspirin monograph, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Antiplatelet / NSAID — Irreversible COX-1 inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Enteric-coated tablets (100 mg), Dispersible tablets (300 mg). (Astrix, Cartia, Cardiprin, Aspro)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 300 mg STAT (chewed or dissolved). Max **150 mg/day** (For cardiac use). Doses up to 4g/day are historically used for pain/rheumatology but are obsolete due to toxicity." + }, + { + "label": "Key Indication Doses", + "value": "Acute ACS / STEMI: **PO** 300 mg STAT (chewed or dissolved). Secondary Prevention (MI/CVA): **PO** 100 mg **OD**. Analgesia (Obsolete): **PO** 300-900 mg q4-6h (Do not use on the ward. Use Paracetamol/Ibuprofen)." + }, + { + "label": "Best Uses", + "value": "Aspirin is essential for secondary prevention of cardiovascular and cerebrovascular events, but is no longer recommended for primary prevention due to bleeding risk outweighing benefit." + }, + { + "label": "Avoid / Cautions", + "value": "Active bleeding (e.g., active peptic ulcer), hemophilia, children < 16 years (Reye's syndrome risk). Avoid high doses in 3rd trimester. Low dose (150mg) is safe and used for pre-eclampsia prophylaxis." + }, + { + "label": "Key Risks", + "value": "Haematological: Bleeding, bruising. Gastrointestinal: Peptic ulcer disease, GI haemorrhage, dyspepsia. Respiratory: Aspirin-exacerbated respiratory disease (AERD) / Bronchospasm in sensitive asthmatics." + }, + { + "label": "Key Interactions", + "value": "Other antiplatelets (Clopidogrel), DOACs, Warfarin, NSAIDs. Massively increases fatal bleed risk. (Dual Antiplatelet Therapy (DAPT) is strictly for stenting/ACS and usually limited to 1-12 months). Ibuprofen competitively binds COX-1, physically blocking Aspirin from accessing the receptor. Take aspirin 2 hours before ibuprofen." + }, + { + "label": "Monitoring", + "value": "Monitor for melaena (black tarry stool) or hematemesis. Routine **FBC** to monitor for slow, silent GI bleeds (dropping hemoglobin)." + }, + { + "label": "Clinical Pearl", + "value": "In an acute heart attack, an enteric-coated 100mg tablet will take too long to dissolve in the stomach. Give a 300mg dispersible tablet, or force the patient to chew the enteric-coated pill to ensure rapid mucosal absorption." + } + ] + }, + { + "slug": "clopidogrel", + "name": "Clopidogrel", + "class": "Anticoagulant", + "subclass": "Antiplatelet", + "category": "Haematology - Antiplatelets", + "accent": "#0284c7", + "tag": "ANTIPLATELET", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "75 mg OD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6 h", + "cls": "", + "flag": "" + }, + { + "label": "Bleeding Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "PPI Interaction", + "value": "OMEPRAZOLE", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Irreversible P2Y12 ADP receptor antagonist. A critical component of Dual Antiplatelet Therapy (DAPT) post-stenting or acute stroke.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **75 mg OD** (Maintenance). Loading doses up to 600 mg.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "It is a prodrug requiring hepatic activation. Genetic poor-metabolisers will gain zero protection and risk stent thrombosis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Clopidogrel is a key antiplatelet for ACS dual therapy and stent protection, but has variable efficacy due to CYP2C19 polymorphisms and must not be combined with omeprazole.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "HIGH — Bleeding, bruising, epistaxis. RARE — Thrombotic thrombocytopenic purpura (TTP).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — GI haemorrhage, dyspepsia.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "LOW — Rash, pruritus.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute ACS / STEMI", + "val": "**PO** 300-600 mg STAT (Loading dose), followed by 75 mg **OD**.", + "tags": [] + }, + { + "key": "Secondary Prevention / Post-Stroke", + "val": "**PO** 75 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Plavix, Iscover", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (75 mg, 300 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute coronary syndromes, recent MI/stroke, established peripheral arterial disease.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Standard partner to Aspirin in DAPT. Often chosen over Ticagrelor when bleeding risk is high or the patient is frail.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active pathological bleeding (peptic ulcer, intracranial haemorrhage).", + "tags": [] + }, + { + "key": "Surgery", + "val": "MANDATORY — Must be ceased 5-7 days prior to elective major surgery.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Clopidogrel pregnancy row is a benefit-risk caution, not an automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Omeprazole and Esomeprazole strongly inhibit **CYP2C19**. This prevents Clopidogrel from converting into its active form, leading to fatal stent thrombosis. Use Pantoprazole instead.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Anticoagulants, NSAIDs, SSRIs (additive bleeding risk).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for signs of bleeding.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Baseline **FBC**. No routine coagulation monitoring required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Pantoprazole Rule", + "val": "If a patient on Clopidogrel needs gastric protection, ONLY prescribe Pantoprazole or Rabeprazole. Omeprazole will shut down the drug's efficacy.", + "tags": [] + }, + { + "key": "Genetic Resistance", + "val": "Up to 30% of Pacific Islander and Asian populations lack the CYP2C19 enzyme. Clopidogrel is effectively a sugar pill for them; Ticagrelor or Prasugrel must be used instead.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Irreversibly binds the P2Y12 ADP receptor on platelets, preventing activation and aggregation for the lifespan of the platelet.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2 hours (after loading dose).", + "tags": [] + }, + { + "key": "Duration", + "val": "7-10 Days (Platelet lifespan).", + "tags": [] + }, + { + "key": "Half-life", + "val": "6 hours (active metabolite). Prodrug activated by **CYP2C19**.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - PLAVIX ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Antiplatelet — Irreversible P2Y12 ADP receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (75 mg, 300 mg). (Plavix, Iscover)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 300-600 mg STAT (Loading dose), followed by 75 mg **OD**. Max **75 mg OD** (Maintenance). Loading doses up to 600 mg." + }, + { + "label": "Key Indication Doses", + "value": "Acute ACS / STEMI: **PO** 300-600 mg STAT (Loading dose), followed by 75 mg **OD**. Secondary Prevention / Post-Stroke: **PO** 75 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Clopidogrel is a key antiplatelet for ACS dual therapy and stent protection, but has variable efficacy due to CYP2C19 polymorphisms and must not be combined with omeprazole." + }, + { + "label": "Avoid / Cautions", + "value": "Active pathological bleeding (peptic ulcer, intracranial haemorrhage). **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Haematological: Bleeding, bruising, epistaxis. RARE — Thrombotic thrombocytopenic purpura (TTP). Gastrointestinal: GI haemorrhage, dyspepsia. Dermatological: Rash, pruritus." + }, + { + "label": "Key Interactions", + "value": "Omeprazole and Esomeprazole strongly inhibit **CYP2C19**. This prevents Clopidogrel from converting into its active form, leading to fatal stent thrombosis. Use Pantoprazole instead. Anticoagulants, NSAIDs, SSRIs (additive bleeding risk)." + }, + { + "label": "Monitoring", + "value": "Monitor for signs of bleeding. Baseline **FBC**. No routine coagulation monitoring required." + }, + { + "label": "Clinical Pearl", + "value": "If a patient on Clopidogrel needs gastric protection, ONLY prescribe Pantoprazole or Rabeprazole. Omeprazole will shut down the drug's efficacy." + } + ] + }, + { + "slug": "dipyridamole", + "name": "Dipyridamole", + "class": "Anticoagulant", + "subclass": "Antiplatelet / Vasodilator", + "category": "Haematology - Antiplatelets", + "accent": "#0284c7", + "tag": "ANTIPLATELET", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10 h", + "cls": "", + "flag": "" + }, + { + "label": "Headache", + "value": "SEVERE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Combination", + "value": "WITH ASPIRIN", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Antiplatelet agent with potent vasodilatory properties. Primarily used in combination with Aspirin for secondary stroke prevention.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mg/day** (Extended Release).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The massive vasodilation frequently causes agonizing, throbbing headaches that force patients to abandon the drug. Do not use in severe angina (coronary steal).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dipyridamole is an antiplatelet agent used with aspirin for secondary stroke prevention, but causes significant headache and flushing and has largely been superseded by other antiplatelet agents.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Throbbing headache, dizziness (due to vasodilation).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CRITICAL — 'Coronary Steal' syndrome. Dilates healthy coronary arteries, stealing blood away from narrowed/diseased arteries, provoking angina or MI in susceptible patients. Hypotension.", + "tags": [] + }, + { + "key": "Haematological", + "val": "HIGH — Bleeding (especially when combined with Aspirin).", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Secondary Stroke Prevention", + "val": "**PO** 200 mg (SR) **BD**. (Almost universally prescribed as the combination pill Asasantin SR: 200mg Dipyridamole + 25mg Aspirin BD).", + "tags": [] + }, + { + "key": "Cardiac Stress Testing", + "val": "**IV** Infusion (used diagnostically by cardiologists to dilate coronary arteries).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Persantin, Asasantin SR (combo with Aspirin)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (100 mg). SR Capsules (200 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** diagnostic use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for stroke prevention.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Secondary prevention of ischemic stroke and TIA.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Superseded largely by Clopidogrel monotherapy due to terrible headache side effects, but still utilized by some neurologists based on the ESPRIT trial.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe coronary artery disease, recent MI, unstable angina, severe hypotension.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Dipyridamole pregnancy row is a benefit-risk caution, not an automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive bleeding risk with other anticoagulants. Additive hypotension with antihypertensives.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Warn the patient about the severe headache during the first week. Tell them to persist and use Paracetamol; it usually fades as the body adapts.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Headache Hack", + "val": "If starting Asasantin SR (combo pill), neurologists sometimes start with 1 capsule at night for a week before moving to BD, allowing the patient to sleep through the worst of the initial vasodilation headache.", + "tags": [] + }, + { + "key": "The Stress Test", + "val": "Cardiologists intentionally use IV Dipyridamole to trigger 'coronary steal' during a myocardial perfusion scan to diagnose blockages in patients who cannot run on a treadmill.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits phosphodiesterase, increasing cAMP in platelets, preventing aggregation. Also blocks cellular uptake of adenosine, causing profound peripheral and coronary vasodilation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10 hours (requires BD dosing). Hepatically metabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DIPYRASP/Asasantin ARTG evidence and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Antiplatelet / Vasodilator — Antiplatelet agent with potent vasodilatory properties." + }, + { + "label": "Route / Formulation", + "value": "Tablets (100 mg). SR Capsules (200 mg). (Persantin, Asasantin SR (combo with Aspirin))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 200 mg (SR) **BD**. (Almost universally prescribed as the combination pill Asasantin SR: 200mg Dipyridamole + 25mg Aspirin BD). Max **400 mg/day** (Extended Release)." + }, + { + "label": "Key Indication Doses", + "value": "Secondary Stroke Prevention: **PO** 200 mg (SR) **BD**. (Almost universally prescribed as the combination pill Asasantin SR: 200mg Dipyridamole + 25mg Aspirin BD). Cardiac Stress Testing: **IV** Infusion (used diagnostically by cardiologists to dilate coronary arteries)." + }, + { + "label": "Best Uses", + "value": "Dipyridamole is an antiplatelet agent used with aspirin for secondary stroke prevention, but causes significant headache and flushing and has largely been superseded by other antiplatelet agents." + }, + { + "label": "Avoid / Cautions", + "value": "Severe coronary artery disease, recent MI, unstable angina, severe hypotension. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Neurological: Throbbing headache, dizziness (due to vasodilation). Cardiovascular: 'Coronary Steal' syndrome. Dilates healthy coronary arteries, stealing blood away from narrowed/diseased arteries, provoking angina or MI in susceptible patients. Hypotension. Haematological: Bleeding (especially when combined with Aspirin)." + }, + { + "label": "Key Interactions", + "value": "Additive bleeding risk with other anticoagulants. Additive hypotension with antihypertensives." + }, + { + "label": "Monitoring", + "value": "Warn the patient about the severe headache during the first week. Tell them to persist and use Paracetamol; it usually fades as the body adapts." + }, + { + "label": "Clinical Pearl", + "value": "If starting Asasantin SR (combo pill), neurologists sometimes start with 1 capsule at night for a week before moving to BD, allowing the patient to sleep through the worst of the initial vasodilation headache." + } + ] + }, + { + "slug": "ticagrelor", + "name": "Ticagrelor", + "class": "Anticoagulant", + "subclass": "Antiplatelet", + "category": "Haematology - Antiplatelets", + "accent": "#0284c7", + "tag": "ANTIPLATELET", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "90 mg BD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "7 h", + "cls": "", + "flag": "" + }, + { + "label": "Dyspnoea", + "value": "COMMON", + "cls": "warn", + "flag": "" + }, + { + "label": "Bleeding Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent, *reversible* P2Y12 ADP receptor antagonist. Faster and stronger than Clopidogrel, but carries a higher bleeding risk and requires twice-daily dosing.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **90 mg BD** (Maintenance).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Unlike Clopidogrel, it is NOT a prodrug. It works instantly and reliably in all genetic profiles.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ticagrelor is the preferred P2Y12 inhibitor in ACS with faster onset and superior outcomes to Clopidogrel, but causes dyspnoea and requires twice-daily dosing affecting adherence.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Major bleeding (higher risk than Clopidogrel).", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Dyspnoea (shortness of breath). Very common, usually benign and transient, caused by adenosine accumulation in the lungs.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Bradycardia, ventricular pauses (usually in the first week of therapy).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute ACS / STEMI", + "val": "**PO** 180 mg STAT (Loading dose), then 90 mg **BD** for 12 months.", + "tags": [] + }, + { + "key": "Extended Prevention", + "val": "**PO** 60 mg **BD** (Can be used beyond 12 months post-MI in high-risk patients).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Brilinta", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (60 mg, 90 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute coronary syndromes (STEMI, NSTEMI, Unstable Angina) alongside Aspirin.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Preferred over Clopidogrel for ACS in WA Health due to superior mortality benefit (PLATO trial), provided bleeding risk is acceptable.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active bleeding, history of intracranial haemorrhage, severe hepatic impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Surgery", + "val": "MANDATORY — Cease 5 days prior to major elective surgery.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Ticagrelor pregnancy row is a benefit-risk caution, not an automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Metabolised by **CYP3A4**. Strong inhibitors (ketoconazole, clarithromycin) drastically increase bleeding risk.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — High-dose Aspirin (>150 mg/day) reduces the efficacy of Ticagrelor. Aspirin dose MUST be strictly 100 mg/day.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for bleeding. Reassure patients who experience mild shortness of breath without hypoxia.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Baseline **FBC**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Dyspnoea Panic", + "val": "Ticagrelor causes a unique sensation of breathlessness in ~15% of patients. If their SpO2, chest auscultation, and CXR are completely normal, this is a benign side effect. Do not blindly treat for APO.", + "tags": [] + }, + { + "key": "The BD Danger", + "val": "Because it is reversible and has a short half-life, missing a single dose of Ticagrelor leaves a fresh stent completely unprotected within 12 hours. Adherence is paramount.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Direct-acting, reversible P2Y12 receptor antagonist. Does not require hepatic activation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "3-4 Days (Platelet function recovers faster than with Clopidogrel due to reversibility).", + "tags": [] + }, + { + "key": "Half-life", + "val": "7 hours (Requires strict **BD** dosing).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - BRILINTA ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Antiplatelet — Highly potent, *reversible* P2Y12 ADP receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (60 mg, 90 mg). (Brilinta)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 180 mg STAT (Loading dose), then 90 mg **BD** for 12 months. Max **90 mg BD** (Maintenance)." + }, + { + "label": "Key Indication Doses", + "value": "Acute ACS / STEMI: **PO** 180 mg STAT (Loading dose), then 90 mg **BD** for 12 months. Extended Prevention: **PO** 60 mg **BD** (Can be used beyond 12 months post-MI in high-risk patients)." + }, + { + "label": "Best Uses", + "value": "Ticagrelor is the preferred P2Y12 inhibitor in ACS with faster onset and superior outcomes to Clopidogrel, but causes dyspnoea and requires twice-daily dosing affecting adherence." + }, + { + "label": "Avoid / Cautions", + "value": "Active bleeding, history of intracranial haemorrhage, severe hepatic impairment. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Haematological: Major bleeding (higher risk than Clopidogrel). Respiratory: Dyspnoea (shortness of breath). Very common, usually benign and transient, caused by adenosine accumulation in the lungs. Cardiovascular: Bradycardia, ventricular pauses (usually in the first week of therapy)." + }, + { + "label": "Key Interactions", + "value": "Metabolised by **CYP3A4**. Strong inhibitors (ketoconazole, clarithromycin) drastically increase bleeding risk. High-dose Aspirin (>150 mg/day) reduces the efficacy of Ticagrelor. Aspirin dose MUST be strictly 100 mg/day." + }, + { + "label": "Monitoring", + "value": "Monitor for bleeding. Reassure patients who experience mild shortness of breath without hypoxia. Baseline **FBC**." + }, + { + "label": "Clinical Pearl", + "value": "Ticagrelor causes a unique sensation of breathlessness in ~15% of patients. If their SpO2, chest auscultation, and CXR are completely normal, this is a benign side effect. Do not blindly treat for APO." + } + ] + }, + { + "slug": "gentamicin", + "name": "Gentamicin", + "class": "Antibiotic", + "subclass": "Aminoglycoside", + "category": "Infectious Diseases - Aminoglycosides", + "accent": "#ea580c", + "tag": "AMINOGLYCOSIDE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "7 mg/kg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-3 h", + "cls": "", + "flag": "" + }, + { + "label": "Nephrotoxic", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Ototoxic", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Incredibly potent, rapid-acting bactericidal aminoglycoside. Devastates gram-negative aerobes (including Pseudomonas). Exhibits unique 'concentration-dependent' killing.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **7 mg/kg/day** (strictly based on Ideal Body Weight).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Narrow therapeutic index. Permanently destroys hearing and kidneys if blood levels are not aggressively monitored.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Gentamicin is a potent aminoglycoside for serious gram-negative infections and synergistic endocarditis therapy, but has critical nephrotoxicity and irreversible ototoxicity requiring therapeutic drug monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal", + "val": "CRITICAL — Acute tubular necrosis (AKI). Usually reversible if caught early.", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Vestibulocochlear toxicity. Causes permanent, irreversible deafness and severe vertigo by destroying hair cells in the inner ear.", + "tags": [] + }, + { + "key": "Neuromuscular", + "val": "HIGH — Can block neuromuscular transmission, worsening Myasthenia Gravis or deepening surgical blockade.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Empiric Sepsis", + "val": "**IV** 4-7 mg/kg **OD** (Once daily dosing maximizes peak killing while allowing troughs to drop to zero, saving the kidneys).", + "tags": [] + }, + { + "key": "Endocarditis Synergy", + "val": "**IV** 1 mg/kg **q8h** (Targeting different peak/trough kinetics, specialist only).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** is reduced, increase the interval (e.g., give every 36h or 48h) to allow the drug to wash out.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "DBL Gentamicin", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (80 mg/2 mL) for **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe gram-negative sepsis, pyelonephritis, endocarditis synergy, intra-abdominal sepsis.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Often used as a single STAT dose in ED to rapidly sterilize the blood, followed by a safer beta-lactam.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Myasthenia gravis, pre-existing significant hearing loss.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Causes irreversible congenital deafness.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Obesity", + "val": "CRITICAL — Gentamicin is water-soluble; it does not enter fat. Dosing based on Total Body Weight in an obese patient will cause a massive, fatal overdose. MUST use Ideal Body Weight (IBW) + 0.4(Total - IBW).", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Other nephrotoxic or ototoxic drugs, including vancomycin, loop diuretics, NSAIDs and contrast, can markedly increase gentamicin kidney/ear toxicity risk; avoid combinations where possible and monitor renal function/drug levels closely.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **TDM** (Therapeutic Drug Monitoring). Trough levels MUST be checked before the 2nd or 3rd dose. Trough must be < 1.0 mg/L to prevent toxicity. Daily **U&E** is mandatory.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Ask patient daily about tinnitus, ringing in the ears, or dizziness. Stop drug immediately if present.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Trough Target", + "val": "Gentamicin causes kidney damage not from the massive peak dose, but from a persistent high trough. The kidneys need 12 hours of 'zero drug' to recover. If the trough is > 1.0, you must delay the next dose.", + "tags": [] + }, + { + "key": "The Anaerobe Rule", + "val": "Gentamicin requires oxygen-dependent active transport to get inside the bacterial cell. Therefore, it is 100% useless against anaerobic bacteria (like those in deep abscesses).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Irreversibly binds the 30S ribosomal subunit, causing misreading of mRNA. Highly bactericidal. Exhibits a 'post-antibiotic effect' (continues killing bacteria even when blood levels drop to zero).", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Rapid peak at 30 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours (excreted 100% unchanged via glomerular filtration).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - Pfizer Gentamicin ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Aminoglycoside — Incredibly potent, rapid-acting bactericidal aminoglycoside." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (80 mg/2 mL) for **IV** infusion. (DBL Gentamicin)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 4-7 mg/kg **OD** (Once daily dosing maximizes peak killing while allowing troughs to drop to zero, saving the kidneys). Max **7 mg/kg/day** (strictly based on Ideal Body Weight)." + }, + { + "label": "Key Indication Doses", + "value": "Empiric Sepsis: **IV** 4-7 mg/kg **OD** (Once daily dosing maximizes peak killing while allowing troughs to drop to zero, saving the kidneys). Endocarditis Synergy: **IV** 1 mg/kg **q8h** (Targeting different peak/trough kinetics, specialist only). Renal Impairment: If **eGFR** is reduced, increase the interval (e.g., give every 36h or 48h) to allow the drug to wash out." + }, + { + "label": "Best Uses", + "value": "Gentamicin is a potent aminoglycoside for serious gram-negative infections and synergistic endocarditis therapy, but has critical nephrotoxicity and irreversible ototoxicity requiring therapeutic drug monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Myasthenia gravis, pre-existing significant hearing loss. **Pregnancy** Category D. Causes irreversible congenital deafness." + }, + { + "label": "Key Risks", + "value": "Renal: Acute tubular necrosis (AKI). Usually reversible if caught early. Neurological: Vestibulocochlear toxicity. Causes permanent, irreversible deafness and severe vertigo by destroying hair cells in the inner ear. Neuromuscular: Can block neuromuscular transmission, worsening Myasthenia Gravis or deepening surgical blockade." + }, + { + "label": "Key Interactions", + "value": "Vancomycin, Frusemide, NSAIDs, contrast dye. Co-administration guarantees synergistic nephrotoxicity and ototoxicity." + }, + { + "label": "Monitoring", + "value": "**TDM** (Therapeutic Drug Monitoring). Trough levels MUST be checked before the 2nd or 3rd dose. Trough must be < 1.0 mg/L to prevent toxicity. Daily **U&E** is mandatory. Ask patient daily about tinnitus, ringing in the ears, or dizziness. Stop drug immediately if present." + }, + { + "label": "Clinical Pearl", + "value": "Gentamicin causes kidney damage not from the massive peak dose, but from a persistent high trough. The kidneys need 12 hours of 'zero drug' to recover. If the trough is > 1.0, you must delay the next dose." + } + ] + }, + { + "slug": "fluconazole", + "name": "Fluconazole", + "class": "Antifungal", + "subclass": "Triazole", + "category": "Infectious Diseases - Antifungals", + "accent": "#ea580c", + "tag": "ANTIFUNGAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "800 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "30 h", + "cls": "", + "flag": "" + }, + { + "label": "CYP Inhibitor", + "value": "POTENT", + "cls": "hi", + "flag": "warn" + }, + { + "label": "QTc Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly bioavailable triazole antifungal. Excellent against Candida albicans and Cryptococcus. Lacks coverage against Aspergillus or Candida krusei/glabrata.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **800 mg/day** (Loading doses in severe cryptococcal meningitis). Standard max is 400 mg/day.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Potent inhibitor of CYP2C9 and CYP3A4. Massive interaction risk with Warfarin, Statins, and DOACs.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Fluconazole is the first-line systemic antifungal for candidiasis with excellent oral bioavailability, but is a potent CYP2C19/3A4 inhibitor with significant drug interactions including warfarin.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Hepatic", + "val": "HIGH — Transaminitis, rare severe hepatic toxicity/failure.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Cardiovascular", + "val": "HIGH — **QTc** prolongation, Torsades de Pointes.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea, abdominal pain, diarrhea.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Vaginal Candidiasis", + "val": "**PO** 150 mg STAT single dose.", + "tags": [] + }, + { + "key": "Oropharyngeal/Esophageal Thrush", + "val": "**PO** 200 mg load, then 100-200 mg **OD** for 7-14 days.", + "tags": [] + }, + { + "key": "Invasive Candidiasis", + "val": "**IV** / **PO** 800 mg load, then 400 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Halve the maintenance dose if **eGFR** < 50.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Diflucan, Dizole", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (50 mg, 100 mg, 150 mg, 200 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Infusion bags (200 mg/100 mL) for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S3) for 150mg single dose. Prescription (S4) for others.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Mucosal/Systemic Candidiasis, Cryptococcal meningitis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line for susceptible Candida. Exceptional CNS penetration makes it the maintenance drug of choice for fungal meningitis.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Avoid co-administration with strong QTc-prolonging drugs or CYP3A4 substrates where increased exposure can cause serious/fatal toxicity; check the interaction profile before prescribing.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Fluconazole can contribute to QTc risk and clinically important interaction toxicity; review co-prescribed QT-prolonging/CYP3A4 medicines." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category D (High doses are teratogenic. Single 150mg dose is debated but often avoided).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Fluconazole pregnancy row remains a Category D/high-dose teratogenicity caution rather than an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — **Warfarin**. Fluconazole shuts down CYP2C9, causing Warfarin levels to skyrocket. INR will spike dangerously. Halve the Warfarin dose and monitor tightly.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Statins (increased rhabdomyolysis), Phenytoin (toxicity), DOACs (bleeding).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and routine **LFTs** (hepatic toxicity) and **U&E** (reduce dose in CKD).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Cardiac", + "val": "MANDATORY — **ECG** for QTc assessment if combining with other psych/cardiac drugs.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Glabrata Gap", + "val": "Fluconazole is brilliant for Candida albicans (common thrush). However, Candida glabrata and Candida krusei are intrinsically resistant. If a severely ill ICU patient is growing Candida in the blood, start an Echinocandin (Caspofungin) until species is identified.", + "tags": [] + }, + { + "key": "The PO Switch", + "val": "Oral bioavailability is >90%. Unless the patient is vomiting or NBM, IV Fluconazole is a waste of nursing time and vascular access. Switch to oral immediately.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits fungal cytochrome P450 enzyme 14-alpha-demethylase. This halts the synthesis of ergosterol, critically damaging the fungal cell membrane.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "30 hours. Excellent oral bioavailability (>90%). Renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DIFLUCAN fluconazole ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Triazole — Highly bioavailable triazole antifungal." + }, + { + "label": "Route / Formulation", + "value": "Capsules (50 mg, 100 mg, 150 mg, 200 mg). (Diflucan, Dizole)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 150 mg STAT single dose. Max **800 mg/day** (Loading doses in severe cryptococcal meningitis). Standard max is 400 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Vaginal Candidiasis: **PO** 150 mg STAT single dose. Oropharyngeal/Esophageal Thrush: **PO** 200 mg load, then 100-200 mg **OD** for 7-14 days. Invasive Candidiasis: **IV** / **PO** 800 mg load, then 400 mg **OD**. Renal Impairment: Halve the maintenance dose if **eGFR** < 50." + }, + { + "label": "Best Uses", + "value": "Fluconazole is the first-line systemic antifungal for candidiasis with excellent oral bioavailability, but is a potent CYP2C19/3A4 inhibitor with significant drug interactions including warfarin." + }, + { + "label": "Avoid / Cautions", + "value": "Co-administration with other strong QTc prolonging drugs (e.g., Erythromycin, Amiodarone) or drugs metabolized by CYP3A4 that cause fatal toxicity (e.g., Colchicine). **Pregnancy** Category D (High doses are teratogenic. Single 150mg dose is debated but often avoided)." + }, + { + "label": "Key Risks", + "value": "Hepatic: Transaminitis, rare severe hepatic toxicity/failure. Cardiovascular: **QTc** prolongation, Torsades de Pointes. Gastrointestinal: Nausea, abdominal pain, diarrhea." + }, + { + "label": "Key Interactions", + "value": "**Warfarin**. Fluconazole shuts down CYP2C9, causing Warfarin levels to skyrocket. INR will spike dangerously. Halve the Warfarin dose and monitor tightly. Statins (increased rhabdomyolysis), Phenytoin (toxicity), DOACs (bleeding)." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **LFTs** (hepatic toxicity) and **U&E** (reduce dose in CKD). **ECG** for QTc assessment if combining with other psych/cardiac drugs." + }, + { + "label": "Clinical Pearl", + "value": "Fluconazole is brilliant for Candida albicans (common thrush). However, Candida glabrata and Candida krusei are intrinsically resistant. If a severely ill ICU patient is growing Candida in the blood, start an Echinocandin (Caspofungin) until species is identified." + } + ] + }, + { + "slug": "nystatin", + "name": "Nystatin", + "class": "Antifungal", + "subclass": "Polyene", + "category": "Infectious Diseases - Antifungals", + "accent": "#ea580c", + "tag": "ANTIFUNGAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "4 Million U/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "Not Absorbed", + "cls": "", + "flag": "" + }, + { + "label": "Route", + "value": "TOPICAL/PO", + "cls": "purple", + "flag": "" + }, + { + "label": "Systemic Abs.", + "value": "ZERO", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly toxic polyene antifungal that is completely un-absorbable by the human gut. Acts as a brilliant, safe topical/luminal agent to kill Candida (Thrush) on contact.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 Million Units/day** (e.g., 1 mL (100,000 U) QID for oral drops).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must physically touch the fungus to kill it. Swallowing it like a normal pill does absolutely nothing for mouth ulcers.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Nystatin is a topical/oral antifungal for mucocutaneous candidiasis with no systemic absorption, but must be held in the mouth as long as possible for oral thrush and has no systemic antifungal activity.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "LOW — Mild nausea, vomiting, diarrhea (only at massive oral doses).", + "tags": [] + }, + { + "key": "Systemic", + "val": "SAFE — Because it cannot enter the bloodstream, it has zero liver, cardiac, or renal toxicity.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Oral Candidiasis (Thrush)", + "val": "**PO** 1 mL (100,000 Units) **QID**. Swish the liquid around the mouth for as long as possible (minutes) before swallowing.", + "tags": [] + }, + { + "key": "Intestinal Candidiasis", + "val": "**PO** 500,000 to 1,000,000 Units (Tablets) **TDS** to **QID**.", + "tags": [] + }, + { + "key": "Cutaneous Thrush", + "val": "**Topical** Apply cream/ointment to affected skin (e.g., beneath breasts, groin) **BD** to **QID**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nilstat, Mycostatin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Oral drops/suspension (100,000 U/mL). Capsules (500,000 U).", + "tags": [] + }, + { + "key": "Topical", + "val": "Cream, Ointment (100,000 U/g).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S2/S3) for topical/drops. S4 for capsules.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Treatment and prophylaxis of oral, intestinal, and cutaneous Candida albicans infections.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line for simple oral thrush (e.g., secondary to steroid inhaler use). Replaced by Fluconazole if infection is severe or extends down the esophagus.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "NONE — Extremely safe due to lack of systemic absorption.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. Minimal systemic absorption; compatible with breastfeeding and paediatric/neonatal oral thrush use when clinically indicated.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation", "paediatric"], + "action": "info", + "severity": "info", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Nystatin pregnancy/lactation/paediatric row is source-reviewed safe-use context, not a contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "NONE — No systemic drug interactions.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure patient removes dentures before using oral drops, and cleans dentures thoroughly to prevent re-infection. Instruct them to NOT eat or drink for 30 mins after swishing the drops.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Swish and Swallow", + "val": "Nystatin only works by contact. If a patient immediately gulps the liquid down, it will completely fail to cure their mouth thrush. It must be held in the mouth and swished over the plaques.", + "tags": [] + }, + { + "key": "The Esophageal Failure", + "val": "If a patient complains of pain *when swallowing* (odynophagia), the thrush has moved into their esophagus. Nystatin liquid washes past the esophagus too fast to kill it. You MUST switch to systemic oral Fluconazole.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds strongly to ergosterol in the fungal cell membrane, forming pores/channels. Potassium and essential cellular components leak out, causing instant fungal cell death.", + "tags": [] + }, + { + "key": "Onset", + "val": "Rapid local action.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Not applicable. 100% of the oral dose is excreted unchanged in the feces.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - MYCOSTATIN nystatin ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Polyene — Highly toxic polyene antifungal that is completely un-absorbable by the human gut." + }, + { + "label": "Route / Formulation", + "value": "Oral drops/suspension (100,000 U/mL). Capsules (500,000 U). (Nilstat, Mycostatin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1 mL (100,000 Units) **QID**. Swish the liquid around the mouth for as long as possible (minutes) before swallowing. Max **4 Million Units/day** (e.g., 1 mL (100,000 U) QID for oral drops)." + }, + { + "label": "Key Indication Doses", + "value": "Oral Candidiasis (Thrush): **PO** 1 mL (100,000 Units) **QID**. Swish the liquid around the mouth for as long as possible (minutes) before swallowing. Intestinal Candidiasis: **PO** 500,000 to 1,000,000 Units (Tablets) **TDS** to **QID**. Cutaneous Thrush: **Topical** Apply cream/ointment to affected skin (e.g., beneath breasts, groin) **BD** to **QID**." + }, + { + "label": "Best Uses", + "value": "Nystatin is a topical/oral antifungal for mucocutaneous candidiasis with no systemic absorption, but must be held in the mouth as long as possible for oral thrush and has no systemic antifungal activity." + }, + { + "label": "Avoid / Cautions", + "value": "NONE — Extremely safe due to lack of systemic absorption. **Pregnancy** Category A. Safe for breastfeeding infants (used commonly for neonatal oral thrush)." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Mild nausea, vomiting, diarrhea (only at massive oral doses). Systemic: Because it cannot enter the bloodstream, it has zero liver, cardiac, or renal toxicity." + }, + { + "label": "Key Interactions", + "value": "NONE — No systemic drug interactions." + }, + { + "label": "Monitoring", + "value": "Ensure patient removes dentures before using oral drops, and cleans dentures thoroughly to prevent re-infection. Instruct them to NOT eat or drink for 30 mins after swishing the drops." + }, + { + "label": "Clinical Pearl", + "value": "Nystatin only works by contact. If a patient immediately gulps the liquid down, it will completely fail to cure their mouth thrush. It must be held in the mouth and swished over the plaques." + } + ] + }, + { + "slug": "aciclovir", + "name": "Aciclovir", + "class": "Antiviral", + "subclass": "Guanosine Analogue", + "category": "Infectious Diseases - Antivirals", + "accent": "#ea580c", + "tag": "ANTIVIRAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Weight Based IV", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-3 h", + "cls": "", + "flag": "" + }, + { + "label": "Renal Toxicity", + "value": "CRYSTALS", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Bioavailability", + "value": "POOR (15%)", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The foundational anti-herpetic antiviral. Highly effective against HSV and VZV. Oral formulation has terrible bioavailability, requiring frequent dosing, but IV formulation is life-saving for CNS infections.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **800 mg 5 times a day** (PO for shingles). IV doses are 10 mg/kg q8h.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "IV Aciclovir rapidly crystallizes in the renal tubules, causing severe Acute Kidney Injury. Aggressive IV hydration is mandatory.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Aciclovir is the first-line antiviral for HSV and VZV infections, but requires adequate hydration to prevent crystalline nephropathy and dose adjustment in renal impairment.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal", + "val": "CRITICAL — Acute Kidney Injury due to intratubular crystal precipitation (especially if dehydrated or pushed IV too fast).", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Encephalopathy, tremors, seizures, coma (Occurs when the drug accumulates in renal failure and crosses into the brain).", + "tags": [] + }, + { + "key": "Tissue", + "val": "HIGH — Severe phlebitis and necrosis if IV fluid extravasates (pH is highly alkaline).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "HSV Encephalitis", + "val": "**IV** 10 mg/kg q8h (Run over 1 hour to prevent crystallization).", + "tags": [] + }, + { + "key": "Genital Herpes / Cold Sores", + "val": "**PO** 200 mg 5 times a day, or 400 mg **TDS**.", + "tags": [] + }, + { + "key": "Herpes Zoster (Shingles)", + "val": "**PO** 800 mg 5 times a day for 7 days.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Extremely strict dose reduction required if **eGFR** < 50 to prevent fatal neurotoxicity.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zovirax", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (200 mg, 800 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for certain indications.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "HSV encephalitis, genital herpes, herpes zoster, varicella (chickenpox) in immunocompromised.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "IV is the absolute gold standard for suspected viral encephalitis. PO has largely been replaced by Valaciclovir for convenience.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Previous severe hypersensitivity.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "HIGH — High risk of neurotoxicity and crystal nephropathy if renal dose adjustment/hydration is missed; reduce dose or extend interval according to renal function.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Aciclovir requires renal dose adjustment and hydration as kidney function declines." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B3 (Extensive data shows it is safe and often required for active genital herpes near term).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Aciclovir pregnancy row is Category B3/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Concurrent nephrotoxic drugs (NSAIDs, Aminoglycosides, Tazocin) exponentially increase AKI risk.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Daily **U&E** and **eGFR** while on IV therapy.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Ensure the patient receives at least 1L of IV fluids alongside the infusion to flush the kidneys and prevent crystals.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Valaciclovir Switch", + "val": "Because PO Aciclovir requires the patient to wake up and take pills 5 times a day, compliance is terrible. Valaciclovir is a prodrug that converts to Aciclovir in the gut, providing 3-5x higher blood levels and allowing BD or TDS dosing. Switch if possible.", + "tags": [] + }, + { + "key": "The 72-Hour Rule", + "val": "For shingles (Herpes Zoster), antivirals only prevent post-herpetic neuralgia if started within 72 hours of the rash appearing. After that, the virus has stopped replicating and the drug is useless.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug activated by viral thymidine kinase. It incorporates into viral DNA and acts as a chain terminator, completely halting viral replication.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate. **PO** 2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours. Renal clearance (glomerular filtration and tubular secretion). Oral bioavailability is a miserable 10-20%.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ACICLOVIR-WGR ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Guanosine Analogue — The foundational anti-herpetic antiviral." + }, + { + "label": "Route / Formulation", + "value": "Tablets (200 mg, 800 mg). (Zovirax)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 10 mg/kg q8h (Run over 1 hour to prevent crystallization). Max **800 mg 5 times a day** (PO for shingles). IV doses are 10 mg/kg q8h." + }, + { + "label": "Key Indication Doses", + "value": "HSV Encephalitis: **IV** 10 mg/kg q8h (Run over 1 hour to prevent crystallization). Genital Herpes / Cold Sores: **PO** 200 mg 5 times a day, or 400 mg **TDS**. Herpes Zoster (Shingles): **PO** 800 mg 5 times a day for 7 days. Renal Impairment: Extremely strict dose reduction required if **eGFR** < 50 to prevent fatal neurotoxicity." + }, + { + "label": "Best Uses", + "value": "Aciclovir is the first-line antiviral for HSV and VZV infections, but requires adequate hydration to prevent crystalline nephropathy and dose adjustment in renal impairment." + }, + { + "label": "Avoid / Cautions", + "value": "Previous severe hypersensitivity. **Pregnancy** Category B3 (Extensive data shows it is safe and often required for active genital herpes near term)." + }, + { + "label": "Key Risks", + "value": "Renal: Acute Kidney Injury due to intratubular crystal precipitation (especially if dehydrated or pushed IV too fast). Neurological: Encephalopathy, tremors, seizures, coma (Occurs when the drug accumulates in renal failure and crosses into the brain). Tissue: Severe phlebitis and necrosis if IV fluid extravasates (pH is highly alkaline)." + }, + { + "label": "Key Interactions", + "value": "Concurrent nephrotoxic drugs (NSAIDs, Aminoglycosides, Tazocin) exponentially increase AKI risk." + }, + { + "label": "Monitoring", + "value": "Daily **U&E** and **eGFR** while on IV therapy. Ensure the patient receives at least 1L of IV fluids alongside the infusion to flush the kidneys and prevent crystals." + }, + { + "label": "Clinical Pearl", + "value": "Because PO Aciclovir requires the patient to wake up and take pills 5 times a day, compliance is terrible. Valaciclovir is a prodrug that converts to Aciclovir in the gut, providing 3-5x higher blood levels and allowing BD or TDS dosing. Switch if possible." + } + ] + }, + { + "slug": "oseltamivir", + "name": "Oseltamivir", + "class": "Antiviral", + "subclass": "Neuraminidase Inhibitor", + "category": "Infectious Diseases - Antivirals", + "accent": "#ea580c", + "tag": "ANTIVIRAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "150 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6-10 h", + "cls": "", + "flag": "" + }, + { + "label": "48-Hour Window", + "value": "CRITICAL", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Psych Risk", + "value": "PAEDS", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Oral neuraminidase inhibitor. The primary antiviral for Influenza A and B. Reduces symptom duration by ~1 day and significantly lowers ICU admission/mortality in high-risk patients.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **150 mg/day** (e.g., 75 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Efficacy drops to near-zero if started more than 48 hours after symptom onset in healthy adults (though still used late in severe ICU cases).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Oseltamivir is the standard antiviral for influenza treatment and prophylaxis, but must be started within 48 hours of symptom onset and provides only modest reduction in illness duration.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, vomiting (Take with food to minimize this, it does not affect absorption).", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Rare but severe neuropsychiatric events (delirium, hallucinations, suicidal behavior), predominantly observed in children and adolescents (Japan data).", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Influenza Treatment", + "val": "**PO** 75 mg **BD** for 5 days. (Must start ASAP, ideally within 48h of fever).", + "tags": [] + }, + { + "key": "Influenza Prophylaxis", + "val": "**PO** 75 mg **OD** for 10 days. (Used during ward outbreaks or for highly vulnerable contacts).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce treatment dose to 30 mg BD if **eGFR** 10-30. Max 30 mg OD if **eGFR** < 10.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Tamiflu", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (30 mg, 45 mg, 75 mg). Oral powder for suspension (6 mg/mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Treatment and post-exposure prophylaxis of Influenza A and B.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Crucial during winter flu seasons to protect frail elderly, pregnant women, and immunocompromised patients from fatal viral pneumonitis.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe hypersensitivity.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1. Influenza in pregnancy is extremely lethal; Oseltamivir is strongly recommended for pregnant women at any stage if they contract the flu.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Oseltamivir pregnancy row is Category B1/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Live Attenuated Influenza Vaccine (LAIV). Oseltamivir will kill the live vaccine. Do not give LAIV within 2 weeks of taking Oseltamivir. (Note: Standard Australian flu shots are INACTIVATED and do not interact).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Counsel carers to monitor children/adolescents for sudden delirium, hallucinations, abnormal behaviour or self-harm ideation after starting oseltamivir.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Monitor paediatric patients for rare neuropsychiatric events during oseltamivir treatment." + } + }, + { + "key": "Laboratory", + "val": "Check **eGFR** in the elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The ICU Exception", + "val": "While the '48-hour rule' applies to healthy people at home, if a patient is admitted to ICU with severe influenza pneumonia on Day 5, we STILL give them Oseltamivir, as evidence shows it continues to reduce mortality in severe systemic disease.", + "tags": [] + }, + { + "key": "The Food Fix", + "val": "The nausea from Tamiflu is intense and causes many patients to abandon the 5-day course. Taking it in the middle of a heavy meal almost entirely eliminates the nausea.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug activated in the liver. Inhibits the viral neuraminidase enzyme on the surface of the influenza virus, physically preventing newly formed viral particles from detaching from the host cell and spreading.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "6-10 hours (Active metabolite). Renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TAMIFLU oseltamivir ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Neuraminidase Inhibitor — Oral neuraminidase inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Capsules (30 mg, 45 mg, 75 mg). Oral powder for suspension (6 mg/mL). (Tamiflu)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 75 mg **BD** for 5 days. (Must start ASAP, ideally within 48h of fever). Max **150 mg/day** (e.g., 75 mg BD)." + }, + { + "label": "Key Indication Doses", + "value": "Influenza Treatment: **PO** 75 mg **BD** for 5 days. (Must start ASAP, ideally within 48h of fever). Influenza Prophylaxis: **PO** 75 mg **OD** for 10 days. (Used during ward outbreaks or for highly vulnerable contacts). Renal Impairment: Reduce treatment dose to 30 mg BD if **eGFR** 10-30. Max 30 mg OD if **eGFR** < 10." + }, + { + "label": "Best Uses", + "value": "Oseltamivir is the standard antiviral for influenza treatment and prophylaxis, but must be started within 48 hours of symptom onset and provides only modest reduction in illness duration." + }, + { + "label": "Avoid / Cautions", + "value": "Severe hypersensitivity. **Pregnancy** Category B1. Influenza in pregnancy is extremely lethal; Oseltamivir is strongly recommended for pregnant women at any stage if they contract the flu." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea, vomiting (Take with food to minimize this, it does not affect absorption). Neurological: Rare but severe neuropsychiatric events (delirium, hallucinations, suicidal behavior), predominantly observed in children and adolescents (Japan data)." + }, + { + "label": "Key Interactions", + "value": "Live Attenuated Influenza Vaccine (LAIV). Oseltamivir will kill the live vaccine. Do not give LAIV within 2 weeks of taking Oseltamivir. (Note: Standard Australian flu shots are INACTIVATED and do not interact)." + }, + { + "label": "Monitoring", + "value": "Warn parents to monitor children closely for sudden bizarre behavior, delirium, or self-harm ideation after starting the drug. Check **eGFR** in the elderly." + }, + { + "label": "Clinical Pearl", + "value": "While the '48-hour rule' applies to healthy people at home, if a patient is admitted to ICU with severe influenza pneumonia on Day 5, we STILL give them Oseltamivir, as evidence shows it continues to reduce mortality in severe systemic disease." + } + ] + }, + { + "slug": "valaciclovir", + "name": "Valaciclovir", + "class": "Antiviral", + "subclass": "Prodrug of Aciclovir", + "category": "Infectious Diseases - Antivirals", + "accent": "#ea580c", + "tag": "ANTIVIRAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "3000 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3 h", + "cls": "", + "flag": "" + }, + { + "label": "Bioavailability", + "value": "HIGH (55%)", + "cls": "good", + "flag": "" + }, + { + "label": "Renal Tox", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "L-valyl ester prodrug of Aciclovir. Provides 3-5 times higher blood levels than oral aciclovir, allowing for massively improved patient compliance (TDS vs 5-times-daily dosing).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **3000 mg/day** (e.g., 1000 mg TDS for Shingles).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Heavily dependent on renal clearance. Failure to reduce the dose in CKD/elderly will cause severe, irreversible neurotoxicity.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Valaciclovir is the oral prodrug of aciclovir with better bioavailability for HSV and VZV, but still requires renal dose adjustment and adequate hydration to prevent crystalluria.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Encephalopathy, agitation, hallucinations, coma, seizures (Occurs when the drug accumulates in unadjusted renal failure).", + "tags": [] + }, + { + "key": "Renal", + "val": "HIGH — Acute Kidney Injury (AKI) due to intratubular crystal precipitation, especially if the patient is dehydrated.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Mild nausea, headache.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Herpes Zoster (Shingles)", + "val": "**PO** 1000 mg **TDS** for 7 days. (Must start within 72 hours of rash onset).", + "tags": [] + }, + { + "key": "Genital Herpes (Initial)", + "val": "**PO** 500 mg **BD** for 5-10 days.", + "tags": [] + }, + { + "key": "Genital Herpes (Suppression)", + "val": "**PO** 500 mg **OD** (or 250 mg BD).", + "tags": [] + }, + { + "key": "Renal Impairment (Shingles)", + "val": "MANDATORY — **eGFR** 30-50: 1000 mg BD. **eGFR** 10-30: 1000 mg OD. **eGFR** < 10: 500 mg OD.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Valtrex, Valtrex Suppression", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (500 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Herpes zoster (shingles), genital herpes, cold sores (HSV-1), CMV prophylaxis post-transplant.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The absolute first-line oral antiviral for VZV and HSV. Has largely rendered oral Aciclovir obsolete.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe hypersensitivity to Valaciclovir or Aciclovir.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "HIGH — Dose frequency must be reduced according to renal function to prevent aciclovir accumulation, AKI and neurotoxicity.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Valaciclovir requires renal dose adjustment as kidney function declines." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B3 (Widely used and safe for peripartum genital herpes suppression).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Valaciclovir pregnancy row is Category B3/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Nephrotoxic drugs (NSAIDs, ACEi, Diuretics) increase the risk of crystal nephropathy. Encourage heavy oral hydration.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **eGFR** before charting the massive 1000 mg TDS Shingles dose. This dose in an 85-year-old is a guaranteed neurotoxic overdose.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Instruct the patient to drink 2-3 Litres of water daily while on the 7-day high-dose course to flush the kidneys.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 72-Hour Window", + "val": "For Shingles, the virus actively replicates for about 3 days. Giving Valaciclovir on Day 5 of the rash does nothing to heal the skin or prevent post-herpetic neuralgia; it just exposes the patient to kidney toxicity. Only prescribe if the rash is fresh (<72h) or actively blistering.", + "tags": [] + }, + { + "key": "The Prodrug Magic", + "val": "The addition of the valine amino acid to aciclovir tricks the peptide transporters in the gut into actively absorbing the drug, massively boosting its delivery to the blood.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug. Rapidly converted in the gut/liver into Aciclovir. Aciclovir acts as a false nucleotide, incorporating into and permanently terminating the viral DNA chain.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3 hours. Bioavailability is 54% (compared to a miserable 10-20% for Aciclovir).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - VALTREX valaciclovir ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Prodrug of Aciclovir — L-valyl ester prodrug of Aciclovir." + }, + { + "label": "Route / Formulation", + "value": "Tablets (500 mg). (Valtrex, Valtrex Suppression)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1000 mg **TDS** for 7 days. (Must start within 72 hours of rash onset). Max **3000 mg/day** (e.g., 1000 mg TDS for Shingles)." + }, + { + "label": "Key Indication Doses", + "value": "Herpes Zoster (Shingles): **PO** 1000 mg **TDS** for 7 days. (Must start within 72 hours of rash onset). Genital Herpes (Initial): **PO** 500 mg **BD** for 5-10 days. Genital Herpes (Suppression): **PO** 500 mg **OD** (or 250 mg BD). Renal Impairment (Shingles): **eGFR** 30-50: 1000 mg BD. **eGFR** 10-30: 1000 mg OD. **eGFR** < 10: 500 mg OD." + }, + { + "label": "Best Uses", + "value": "Valaciclovir is the oral prodrug of aciclovir with better bioavailability for HSV and VZV, but still requires renal dose adjustment and adequate hydration to prevent crystalluria." + }, + { + "label": "Avoid / Cautions", + "value": "Severe hypersensitivity to Valaciclovir or Aciclovir. **Pregnancy** Category B3 (Widely used and safe for peripartum genital herpes suppression)." + }, + { + "label": "Key Risks", + "value": "Neurological: Encephalopathy, agitation, hallucinations, coma, seizures (Occurs when the drug accumulates in unadjusted renal failure). Renal: Acute Kidney Injury (AKI) due to intratubular crystal precipitation, especially if the patient is dehydrated. Gastrointestinal: Mild nausea, headache." + }, + { + "label": "Key Interactions", + "value": "Nephrotoxic drugs (NSAIDs, ACEi, Diuretics) increase the risk of crystal nephropathy. Encourage heavy oral hydration." + }, + { + "label": "Monitoring", + "value": "Check **eGFR** before charting the massive 1000 mg TDS Shingles dose. This dose in an 85-year-old is a guaranteed neurotoxic overdose. Instruct the patient to drink 2-3 Litres of water daily while on the 7-day high-dose course to flush the kidneys." + }, + { + "label": "Clinical Pearl", + "value": "For Shingles, the virus actively replicates for about 3 days. Giving Valaciclovir on Day 5 of the rash does nothing to heal the skin or prevent post-herpetic neuralgia; it just exposes the patient to kidney toxicity. Only prescribe if the rash is fresh (<72h) or actively blistering." + } + ] + }, + { + "slug": "clotrimazole", + "name": "Clotrimazole", + "class": "Antifungal", + "subclass": "Imidazole", + "category": "Infectious Diseases - Antivirals & Antifungals", + "accent": "#ea580c", + "tag": "ANTIFUNGAL", + "schedule": "S3", + "stats": [ + { + "label": "Max Dose", + "value": "Apply BD/TDS", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Systemic Abs.", + "value": "ZERO", + "cls": "good", + "flag": "" + }, + { + "label": "Route", + "value": "TOPICAL/VAGINAL", + "cls": "purple", + "flag": "" + }, + { + "label": "Safety", + "value": "HIGH", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Broad-spectrum topical imidazole antifungal. Highly effective for local dermatophyte and candidal infections. Strictly for external or mucosal use.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Apply topically **BD** or **TDS** until symptoms clear.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Fungal skin infections take weeks to clear. Therapy must continue for 2 weeks AFTER the rash visually disappears to prevent recurrence.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Clotrimazole is a topical azole antifungal for skin and vaginal candidiasis, but is only effective topically and has no systemic activity for invasive fungal infections.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Dermatological", + "val": "LOW — Mild local erythema, stinging, blistering, or contact dermatitis at the application site.", + "tags": [] + }, + { + "key": "Systemic", + "val": "SAFE — Zero systemic toxicity due to lack of absorption.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Tinea (Skin)", + "val": "**Topical** Apply cream **BD** or **TDS** for 2-4 weeks. Continue for 14 days after rash resolves.", + "tags": [] + }, + { + "key": "Vulvovaginal Candidiasis (Thrush)", + "val": "**Vaginal** Insert 1 x 500mg pessary STAT, or 1 x 100mg pessary for 6 consecutive nights. Apply cream to vulva **BD**.", + "tags": [] + }, + { + "key": "Oral Thrush", + "val": "**PO** Dissolve a 10mg lozenge slowly in the mouth 5 times a day (Not available in all regions).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Canesten, Clonea", + "tags": [] + }, + { + "key": "Topical", + "val": "Cream 1%. Vaginal cream (1%, 2%, 10%). Vaginal pessaries (100 mg, 500 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC) or Pharmacy/Pharmacist Only (S2/S3) depending on strength/pack size.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Tinea pedis (athlete's foot), tinea cruris (jock itch), vulvovaginal candidiasis, cutaneous candidiasis.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line topical antifungal. Safe, accessible, and highly effective for superficial infections.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known hypersensitivity. Do not use for ophthalmic (eye) infections.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. The absolute drug of choice for vaginal thrush during pregnancy.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Clotrimazole pregnancy row is Category A/topical-vaginal safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "LOW — Vaginal creams/pessaries contain oils that can degrade latex condoms and diaphragms, causing them to break. Warn patients to use alternative contraception methods.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the area is kept completely dry. Fungi thrive in moist environments. Advise breathable cotton clothing/socks.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 14-Day Rule", + "val": "Fungal spores embed deep in the epidermal layers. If a patient stops applying the cream the day the redness disappears, the embedded spores will hatch a week later and the rash returns. You must treat for 14 days post-clearance to kill the spores.", + "tags": [] + }, + { + "key": "Pregnancy Safety", + "val": "Pregnant women frequently suffer from vaginal thrush. Oral Fluconazole is Category D (teratogenic at high doses). Clotrimazole vaginal pessaries/cream are Category A and perfectly safe.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits the enzyme 14-alpha-demethylase, blocking the synthesis of ergosterol. This destabilizes the fungal cell membrane, causing cellular contents to leak out, resulting in cell death.", + "tags": [] + }, + { + "key": "Onset", + "val": "Relief of itching in days. Eradication of fungus in weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Not applicable. Systemic absorption is < 0.5% through intact skin or mucosa.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CANESTEN clotrimazole ARTG/CMI, TGA scheduling evidence, and PBS check checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Imidazole — Broad-spectrum topical imidazole antifungal." + }, + { + "label": "Route / Formulation", + "value": "Cream 1%. Vaginal cream (1%, 2%, 10%). Vaginal pessaries (100 mg, 500 mg). (Canesten, Clonea)" + }, + { + "label": "Usual Dose & Max", + "value": "**Topical** Apply cream **BD** or **TDS** for 2-4 weeks. Continue for 14 days after rash resolves. Apply topically **BD** or **TDS** until symptoms clear." + }, + { + "label": "Key Indication Doses", + "value": "Tinea (Skin): **Topical** Apply cream **BD** or **TDS** for 2-4 weeks. Continue for 14 days after rash resolves. Vulvovaginal Candidiasis (Thrush): **Vaginal** Insert 1 x 500mg pessary STAT, or 1 x 100mg pessary for 6 consecutive nights. Apply cream to vulva **BD**. Oral Thrush: **PO** Dissolve a 10mg lozenge slowly in the mouth 5 times a day (Not available in all regions)." + }, + { + "label": "Best Uses", + "value": "Clotrimazole is a topical azole antifungal for skin and vaginal candidiasis, but is only effective topically and has no systemic activity for invasive fungal infections." + }, + { + "label": "Avoid / Cautions", + "value": "Known hypersensitivity. Do not use for ophthalmic (eye) infections. **Pregnancy** Category A. The absolute drug of choice for vaginal thrush during pregnancy." + }, + { + "label": "Key Risks", + "value": "Dermatological: Mild local erythema, stinging, blistering, or contact dermatitis at the application site. Systemic: Zero systemic toxicity due to lack of absorption." + }, + { + "label": "Key Interactions", + "value": "Vaginal creams/pessaries contain oils that can degrade latex condoms and diaphragms, causing them to break. Warn patients to use alternative contraception methods." + }, + { + "label": "Monitoring", + "value": "Ensure the area is kept completely dry. Fungi thrive in moist environments. Advise breathable cotton clothing/socks." + }, + { + "label": "Clinical Pearl", + "value": "Fungal spores embed deep in the epidermal layers. If a patient stops applying the cream the day the redness disappears, the embedded spores will hatch a week later and the rash returns. You must treat for 14 days post-clearance to kill the spores." + } + ] + }, + { + "slug": "cefazolin", + "name": "Cefazolin", + "class": "Antibiotic", + "subclass": "1st Gen Cephalosporin", + "category": "Infectious Diseases - Cephalosporins", + "accent": "#ea580c", + "tag": "CEPHALOSPORIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "6 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "Cross-Allergy", + "value": "LOW RISK", + "cls": "good", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "First-generation IV cephalosporin. Outstanding coverage against MSSA and Streptococci. The absolute gold-standard worldwide for surgical site prophylaxis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **6 g/day** (e.g., 2 g TDS).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly renally cleared. Failure to adjust the dose in severe kidney disease will cause neurotoxicity.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Cefazolin is the first-line IV surgical prophylaxis cephalosporin with excellent staphylococcal coverage, but has limited gram-negative spectrum and ~2% cross-reactivity in penicillin-allergic patients.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Immunological", + "val": "MODERATE — Hypersensitivity. (Cross-reactivity with true penicillin allergy is < 2%, but avoid if the patient had recent anaphylaxis).", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea, C. difficile infection.", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Seizures/encephalopathy (if massive doses accumulate in renal failure).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Surgical Prophylaxis", + "val": "**IV** 2 g STAT within 60 mins prior to surgical incision. (Add a further 1 g intra-op if surgery lasts > 4 hours).", + "tags": [] + }, + { + "key": "Severe Cellulitis / MSSA Bacteremia", + "val": "**IV** 2 g q8h.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce frequency. If **eGFR** 10-30, give q12h. If **eGFR** < 10, give 1g q24h.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Kefzol", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (1 g, 2 g powder) for **IV** injection/infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Surgical prophylaxis, severe skin and soft tissue infections, MSSA endocarditis.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Often replaces IV Flucloxacillin in patients who cannot tolerate Flucloxacillin's severe phlebitis or frequent dosing schedule.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Previous cephalosporin anaphylaxis.", + "tags": [], + "patient": { + "factors": ["allergy-ceph"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1. The drug of choice for Caesarean section prophylaxis.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Cefazolin pregnancy row is Category B1/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Exceptionally clean drug interaction profile. Highly safe to use with anaesthetic agents.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Check **eGFR** to ensure appropriate maintenance dosing frequency.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — For surgical prophylaxis, the drug MUST be completely infused *before* the surgeon cuts the skin, otherwise the wound is unprotected.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Weight Rule", + "val": "For surgical prophylaxis in bariatric patients (> 120 kg), a standard 2 g dose does not provide adequate tissue concentrations. The dose MUST be increased to 3 g IV.", + "tags": [] + }, + { + "key": "The Phlebitis Win", + "val": "Unlike Flucloxacillin which rapidly destroys peripheral veins, Cefazolin is incredibly well tolerated by veins. It is the preferred agent for OPAT (Outpatient Parenteral Antimicrobial Therapy) via peripheral lines.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Bactericidal. Binds PBPs and inhibits cell wall synthesis. Highly stable against staphylococcal beta-lactamase.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1.5 - 2 hours. Excreted almost entirely unchanged in the urine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CEPHAZOLIN VIATRIS ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "1st Gen Cephalosporin — First-generation IV cephalosporin." + }, + { + "label": "Route / Formulation", + "value": "Vials (1 g, 2 g powder) for **IV** injection/infusion. (Kefzol)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 2 g STAT within 60 mins prior to surgical incision. (Add a further 1 g intra-op if surgery lasts > 4 hours). Max **6 g/day** (e.g., 2 g TDS)." + }, + { + "label": "Key Indication Doses", + "value": "Surgical Prophylaxis: **IV** 2 g STAT within 60 mins prior to surgical incision. (Add a further 1 g intra-op if surgery lasts > 4 hours). Severe Cellulitis / MSSA Bacteremia: **IV** 2 g q8h. Renal Impairment: Reduce frequency. If **eGFR** 10-30, give q12h. If **eGFR** < 10, give 1g q24h." + }, + { + "label": "Best Uses", + "value": "Cefazolin is the first-line IV surgical prophylaxis cephalosporin with excellent staphylococcal coverage, but has limited gram-negative spectrum and ~2% cross-reactivity in penicillin-allergic patients." + }, + { + "label": "Avoid / Cautions", + "value": "Previous cephalosporin anaphylaxis. **Pregnancy** Category B1. The drug of choice for Caesarean section prophylaxis." + }, + { + "label": "Key Risks", + "value": "Immunological: Hypersensitivity. (Cross-reactivity with true penicillin allergy is < 2%, but avoid if the patient had recent anaphylaxis). Gastrointestinal: Nausea, C. difficile infection. Neurological: Seizures/encephalopathy (if massive doses accumulate in renal failure)." + }, + { + "label": "Key Interactions", + "value": "Exceptionally clean drug interaction profile. Highly safe to use with anaesthetic agents." + }, + { + "label": "Monitoring", + "value": "Check **eGFR** to ensure appropriate maintenance dosing frequency. For surgical prophylaxis, the drug MUST be completely infused *before* the surgeon cuts the skin, otherwise the wound is unprotected." + }, + { + "label": "Clinical Pearl", + "value": "For surgical prophylaxis in bariatric patients (> 120 kg), a standard 2 g dose does not provide adequate tissue concentrations. The dose MUST be increased to 3 g IV." + } + ] + }, + { + "slug": "cefepime", + "name": "Cefepime", + "class": "Antibiotic", + "subclass": "4th Gen Cephalosporin", + "category": "Infectious Diseases - Cephalosporins", + "accent": "#ea580c", + "tag": "CEPHALOSPORIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "6 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "Pseudomonas", + "value": "COVERED", + "cls": "good", + "flag": "" + }, + { + "label": "Neurotoxicity", + "value": "CRITICAL RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Fourth-generation, ultra-broad-spectrum IV cephalosporin. Combines the Gram-positive power of Cefazolin with the Gram-negative (anti-Pseudomonal) power of Ceftazidime.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **6 g/day** (e.g., 2 g q8h for severe Pseudomonas or febrile neutropenia).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Renally cleared. Failure to adjust the dose in kidney disease guarantees severe neurotoxicity (myoclonus, non-convulsive status epilepticus, coma).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Cefepime is a fourth-generation cephalosporin for febrile neutropenia and resistant hospital infections, but can cause neurotoxicity (encephalopathy, seizures) especially in renal impairment.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Cefepime-induced encephalopathy. Presents as confusion, agitation, myoclonus (twitching), and refractory non-convulsive status epilepticus. Almost exclusively occurs in unadjusted renal failure.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — C. difficile infection (destroys normal gut flora).", + "tags": [] + }, + { + "key": "Haematological", + "val": "LOW — Positive Coombs test, rare neutropenia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Febrile Neutropenia / Severe Sepsis", + "val": "**IV** 2 g q8h.", + "tags": [] + }, + { + "key": "Complicated UTI", + "val": "**IV** 1-2 g q12h.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Massive dose reduction required. If **eGFR** 10-30, max 1g q24h. If **eGFR** < 10, max 500mg q24h. The brain relies on the kidneys to clear this drug.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Maxipime", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (1 g, 2 g powder) for **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply. Highly restricted by Antimicrobial Stewardship.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Febrile neutropenia, severe hospital-acquired pneumonia, Pseudomonas infections.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Reserved exclusively for life-threatening, highly resistant hospital-acquired infections or immunocompromised hosts.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Cephalosporin anaphylaxis.", + "tags": [], + "patient": { + "factors": ["allergy-ceph"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Cefepime pregnancy row is Category B1/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "LOW — Generally few drug-drug interactions, but additive neurotoxicity if given with other seizure-threshold lowering drugs (like high-dose Tramadol or Imipenem).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Daily **U&E** and **eGFR**. The dose MUST be recalculated every single day if the patient's renal function is fluctuating in ICU.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — If a patient on Cefepime becomes acutely confused or starts twitching, cease the drug immediately and order an EEG.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Anaerobic Hole", + "val": "Unlike Tazocin or Meropenem, Cefepime has ZERO activity against gut anaerobes (Bacteroides). If you are treating an intra-abdominal perforation or appendicitis with Cefepime, you MUST co-prescribe IV Metronidazole.", + "tags": [] + }, + { + "key": "The Neurotoxic Mask", + "val": "In the ICU, an elderly patient's failure to wake up or clear delirium is often blamed on 'sepsis' or 'ICU delirium'. Always check their Cefepime dose against their eGFR; they might be in a Cefepime coma.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Bactericidal. Binds PBPs. Uniquely structured to rapidly penetrate the outer membrane of Gram-negative bacteria (like Pseudomonas) and is highly resistant to chromosomal AmpC beta-lactamases.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2 hours. Excreted 85% unchanged in urine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CEFEPIME KABI ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "4th Gen Cephalosporin — Fourth-generation, ultra-broad-spectrum IV cephalosporin." + }, + { + "label": "Route / Formulation", + "value": "Vials (1 g, 2 g powder) for **IV** infusion. (Maxipime)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 2 g q8h. Max **6 g/day** (e.g., 2 g q8h for severe Pseudomonas or febrile neutropenia)." + }, + { + "label": "Key Indication Doses", + "value": "Febrile Neutropenia / Severe Sepsis: **IV** 2 g q8h. Complicated UTI: **IV** 1-2 g q12h. Renal Impairment: Massive dose reduction required. If **eGFR** 10-30, max 1g q24h. If **eGFR** < 10, max 500mg q24h. The brain relies on the kidneys to clear this drug." + }, + { + "label": "Best Uses", + "value": "Cefepime is a fourth-generation cephalosporin for febrile neutropenia and resistant hospital infections, but can cause neurotoxicity (encephalopathy, seizures) especially in renal impairment." + }, + { + "label": "Avoid / Cautions", + "value": "Cephalosporin anaphylaxis. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Neurological: Cefepime-induced encephalopathy. Presents as confusion, agitation, myoclonus (twitching), and refractory non-convulsive status epilepticus. Almost exclusively occurs in unadjusted renal failure. Gastrointestinal: C. difficile infection (destroys normal gut flora). Haematological: Positive Coombs test, rare neutropenia." + }, + { + "label": "Key Interactions", + "value": "Generally few drug-drug interactions, but additive neurotoxicity if given with other seizure-threshold lowering drugs (like high-dose Tramadol or Imipenem)." + }, + { + "label": "Monitoring", + "value": "Daily **U&E** and **eGFR**. The dose MUST be recalculated every single day if the patient's renal function is fluctuating in ICU. If a patient on Cefepime becomes acutely confused or starts twitching, cease the drug immediately and order an EEG." + }, + { + "label": "Clinical Pearl", + "value": "Unlike Tazocin or Meropenem, Cefepime has ZERO activity against gut anaerobes (Bacteroides). If you are treating an intra-abdominal perforation or appendicitis with Cefepime, you MUST co-prescribe IV Metronidazole." + } + ] + }, + { + "slug": "ceftriaxone", + "name": "Ceftriaxone", + "class": "Antibiotic", + "subclass": "3rd Gen Cephalosporin", + "category": "Infectious Diseases - Cephalosporins", + "accent": "#ea580c", + "tag": "CEPHALOSPORIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "4 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "8 h", + "cls": "", + "flag": "" + }, + { + "label": "Biliary Sludge", + "value": "RISK", + "cls": "warn", + "flag": "" + }, + { + "label": "Calcium IV", + "value": "FATAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Third-generation cephalosporin. Outstanding gram-negative and pneumococcal coverage, incredible CNS penetration, and a long half-life allowing convenient once-daily dosing.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 g/day** (strictly for meningitis).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "NEVER mix Ceftriaxone with IV Calcium (e.g., Hartmann's, TPN) as it forms fatal intravascular crystalline precipitates.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ceftriaxone is a powerful third-generation cephalosporin for meningitis, sepsis, and gonorrhoea, but must never be co-administered with calcium-containing IV solutions and can cause biliary sludging.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Hepatic / Biliary", + "val": "HIGH — Biliary sludging and 'pseudolithiasis' (reversible gallstones causing RUQ pain).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — C. difficile infection (3rd gen cephalosporins are notorious for wiping out gut flora).", + "tags": [], + "patient": { + "factors": ["allergy-ceph"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Immunological", + "val": "MODERATE — Hypersensitivity. Cross-reacts with severe penicillin allergies (~1-3%).", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe CAP / Pyelonephritis", + "val": "**IV** 1-2 g **OD**.", + "tags": [] + }, + { + "key": "Bacterial Meningitis", + "val": "**IV** 2 g **BD** (Requires massive doses to breach BBB).", + "tags": [] + }, + { + "key": "Gonorrhoea", + "val": "**IM** 500 mg STAT (mixed with 1% lidocaine to prevent severe pain).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "Safe to use without dose adjustment in standard CKD (due to dual biliary/renal clearance).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Rocephin", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (1 g, 2 g) for **IV** or **IM** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply. Restricted.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Meningitis, severe pneumonia, pyelonephritis, gonorrhoea, empiric undifferentiated sepsis.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "The backbone of ED empiric sepsis pathways. Lacks Pseudomonas and Enterococcus coverage.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Neonates ≤ 28 days, especially if premature, hyperbilirubinaemic or receiving/calcium-containing IV solutions, due to kernicterus and fatal calcium-ceftriaxone precipitation risk.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 0.08 + } + }, + "note": "Ceftriaxone neonatal contraindication applies to neonates, not all paediatric patients." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Ceftriaxone pregnancy row is Category B1/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — IV Calcium solutions (Hartmann's, Plasmalyte). Wait 48 hours or use distinct, deeply flushed lines.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Monitor **LFTs** for biliary stasis. Monitor **FBC** (rare hemolytic anemia).", + "tags": [] + }, + { + "key": "Bedside", + "val": "Assess for Right Upper Quadrant pain (biliary sludge).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Renal Win", + "val": "Because Ceftriaxone has dual hepatic and renal clearance, it is one of the very few IV antibiotics that does not require dose reduction in renal failure. Highly useful in acute AKI sepsis.", + "tags": [] + }, + { + "key": "The IM Agony", + "val": "Giving 1g of Ceftriaxone IM is exquisitely painful. It must be reconstituted with 1% Lidocaine (without adrenaline) to make it tolerable for the patient.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds PBPs. Highly resistant to many beta-lactamases. Excellent penetration into CSF.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "8 hours. (Uniquely long for a cephalosporin. Cleared 60% renally, 40% biliary/faecal).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CEFTRIAXONE-AFT ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "3rd Gen Cephalosporin — Third-generation cephalosporin." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (1 g, 2 g) for **IV** or **IM** use. (Rocephin)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 1-2 g **OD**. Max **4 g/day** (strictly for meningitis)." + }, + { + "label": "Key Indication Doses", + "value": "Severe CAP / Pyelonephritis: **IV** 1-2 g **OD**. Bacterial Meningitis: **IV** 2 g **BD** (Requires massive doses to breach BBB). Gonorrhoea: **IM** 500 mg STAT (mixed with 1% lidocaine to prevent severe pain). Renal Impairment: Safe to use without dose adjustment in standard CKD (due to dual biliary/renal clearance)." + }, + { + "label": "Best Uses", + "value": "Ceftriaxone is a powerful third-generation cephalosporin for meningitis, sepsis, and gonorrhoea, but must never be co-administered with calcium-containing IV solutions and can cause biliary sludging." + }, + { + "label": "Avoid / Cautions", + "value": "Neonates ≤ 28 days (Displaces bilirubin from albumin, causing fatal kernicterus, and risks fatal calcium precipitation). **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Hepatic / Biliary: Biliary sludging and 'pseudolithiasis' (reversible gallstones causing RUQ pain). Gastrointestinal: C. difficile infection (3rd gen cephalosporins are notorious for wiping out gut flora). Immunological: Hypersensitivity. Cross-reacts with severe penicillin allergies (~1-3%)." + }, + { + "label": "Key Interactions", + "value": "IV Calcium solutions (Hartmann's, Plasmalyte). Wait 48 hours or use distinct, deeply flushed lines." + }, + { + "label": "Monitoring", + "value": "Monitor **LFTs** for biliary stasis. Monitor **FBC** (rare hemolytic anemia). Assess for Right Upper Quadrant pain (biliary sludge)." + }, + { + "label": "Clinical Pearl", + "value": "Because Ceftriaxone has dual hepatic and renal clearance, it is one of the very few IV antibiotics that does not require dose reduction in renal failure. Highly useful in acute AKI sepsis." + } + ] + }, + { + "slug": "cefuroxime", + "name": "Cefuroxime", + "class": "Antibiotic", + "subclass": "2nd Gen Cephalosporin", + "category": "Infectious Diseases - Cephalosporins", + "accent": "#ea580c", + "tag": "CEPHALOSPORIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "4.5 g/day (IV)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1.5 h", + "cls": "", + "flag": "" + }, + { + "label": "PO Bioavail.", + "value": "POOR", + "cls": "warn", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Second-generation cephalosporin. Bridges the gap by maintaining good Gram-positive cover while expanding Gram-negative cover (Haemophilus, Moraxella).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4.5 g/day** (**IV**) or **1 g/day** (**PO**).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The oral tablet (axetil) is notoriously bitter if crushed and has variable absorption; it must be taken with food.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Cefuroxime is a second-generation cephalosporin bridging oral and IV therapy for respiratory and urinary infections, but has intermediate spectrum and is being replaced by more targeted agents.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Diarrhea, nausea (very common with the oral axetil formulation).", + "tags": [] + }, + { + "key": "Immunological", + "val": "MODERATE — Hypersensitivity rash. Cross-reactivity with penicillin allergy is ~1%.", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe CAP / Intra-abdominal", + "val": "**IV** 1.5 g q8h.", + "tags": [] + }, + { + "key": "LRTI / Lyme Disease (Oral)", + "val": "**PO** 500 mg **BD** with meals.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce IV frequency to q12h if **eGFR** 10-20, and q24h if **eGFR** < 10.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zinnat (Oral), Zinacef (IV)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (250 mg). Do NOT crush (intensely bitter). Oral suspension.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (750 mg, 1.5 g powder) for **IV** or **IM** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for oral. Hospital supply for IV.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Community-Acquired Pneumonia, exacerbations of COPD, surgical prophylaxis (cardiac/thoracic).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "A step-up from Cefazolin/Cephalexin when H. influenzae or resistant respiratory pathogens are suspected.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe cephalosporin hypersensitivity.", + "tags": [], + "patient": { + "factors": ["allergy-ceph"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Cefuroxime pregnancy row is Category B1/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Antacids and PPIs (Pantoprazole) raise gastric pH, which severely drops the absorption of the oral prodrug. Separate by 2 hours or avoid.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure oral doses are taken with food to maximise absorption and reduce GI distress.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** for IV dosing.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Paediatric Challenge", + "val": "The oral liquid suspension has a gritty, terrible taste. Compliance in children is notoriously poor. Mixing it with chocolate milk or strong syrups is often required to get them to swallow it.", + "tags": [] + }, + { + "key": "Surgical Niche", + "val": "Often used by cardiothoracic surgeons for CABG prophylaxis because it perfectly covers skin Staph plus the specific respiratory Gram-negatives common in intubated chest surgeries.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Bactericidal. Inhibits cell wall synthesis. The oral form is a prodrug (cefuroxime axetil) which is hydrolyzed in the gut mucosa to active cefuroxime.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate. **PO** 2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1.5 hours. Excreted almost entirely unchanged by the kidneys.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ZINNAT/CEFUROXIME ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "2nd Gen Cephalosporin — Second-generation cephalosporin." + }, + { + "label": "Route / Formulation", + "value": "Tablets (250 mg). Do NOT crush (intensely bitter). Oral suspension. (Zinnat (Oral), Zinacef (IV))" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 1.5 g q8h. Max **4.5 g/day** (**IV**) or **1 g/day** (**PO**)." + }, + { + "label": "Key Indication Doses", + "value": "Severe CAP / Intra-abdominal: **IV** 1.5 g q8h. LRTI / Lyme Disease (Oral): **PO** 500 mg **BD** with meals. Renal Impairment: Reduce IV frequency to q12h if **eGFR** 10-20, and q24h if **eGFR** < 10." + }, + { + "label": "Best Uses", + "value": "Cefuroxime is a second-generation cephalosporin bridging oral and IV therapy for respiratory and urinary infections, but has intermediate spectrum and is being replaced by more targeted agents." + }, + { + "label": "Avoid / Cautions", + "value": "Severe cephalosporin hypersensitivity. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Diarrhea, nausea (very common with the oral axetil formulation). Immunological: Hypersensitivity rash. Cross-reactivity with penicillin allergy is ~1%." + }, + { + "label": "Key Interactions", + "value": "Antacids and PPIs (Pantoprazole) raise gastric pH, which severely drops the absorption of the oral prodrug. Separate by 2 hours or avoid." + }, + { + "label": "Monitoring", + "value": "Ensure oral doses are taken with food to maximise absorption and reduce GI distress. Check **eGFR** for IV dosing." + }, + { + "label": "Clinical Pearl", + "value": "The oral liquid suspension has a gritty, terrible taste. Compliance in children is notoriously poor. Mixing it with chocolate milk or strong syrups is often required to get them to swallow it." + } + ] + }, + { + "slug": "cephalexin", + "name": "Cephalexin", + "class": "Antibiotic", + "subclass": "1st Gen Cephalosporin", + "category": "Infectious Diseases - Cephalosporins", + "accent": "#ea580c", + "tag": "CEPHALOSPORIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "4 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1 h", + "cls": "", + "flag": "" + }, + { + "label": "Cross-Allergy", + "value": "CAUTION", + "cls": "warn", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "First-generation oral cephalosporin. Outstanding coverage against MSSA and basic Strep. The workhorse for mild-to-moderate skin infections and simple UTIs.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 g/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Approximately 1-5% of patients with a true penicillin allergy will cross-react with cephalosporins.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Cephalexin is a safe, well-tolerated first-generation cephalosporin for skin and simple UTIs, but has limited gram-negative coverage and ~2% cross-reactivity in penicillin allergy.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, diarrhea, mild C. diff risk.", + "tags": [] + }, + { + "key": "Immunological", + "val": "MODERATE — Hypersensitivity rash, rare anaphylaxis.", + "tags": [] + }, + { + "key": "Renal", + "val": "LOW — Interstitial nephritis.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Cellulitis / Skin Infection", + "val": "**PO** 500 mg **QID**.", + "tags": [] + }, + { + "key": "Uncomplicated UTI", + "val": "**PO** 500 mg **BD** for 5 days.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Max 500 mg **BD** if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Keflex, Rilexine", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (250 mg, 500 mg). Oral liquid (125 mg/5mL, 250 mg/5mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Staphylococcal/Streptococcal skin infections, cystitis in pregnancy.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Oral step-down from IV Cefazolin. Excellent safe choice for UTIs during pregnancy.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Cephalosporin anaphylaxis. Avoid in severe immediate (IgE) Penicillin allergy (e.g., hives/anaphylaxis). Safe to use if penicillin allergy is just a mild childhood rash.", + "tags": [], + "patient": { + "factors": ["allergy-pcn", "allergy-ceph"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Cephalexin pregnancy row is Category A/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Generally free of major liver/CYP interactions.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Check **eGFR** if using high doses (**QID**) in the elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "QID vs BD", + "val": "Cephalexin has a very short half-life (1 hour). For a tissue infection like cellulitis, dosing it **QID** (every 6 hours) is mandatory to maintain blood levels. Dosing it BD for skin guarantees clinical failure.", + "tags": [] + }, + { + "key": "UTI Exception", + "val": "Because Cephalexin concentrates massively in the urine, it *can* be dosed **BD** for simple cystitis, as the urinary levels remain high enough for 12 hours.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Bactericidal. Binds to PBPs, inhibiting cell wall synthesis. Highly resistant to staphylococcal beta-lactamase.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1 hour.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1 hour. Almost 100% renally excreted unchanged.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CEPHALEXIN-WGR ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "1st Gen Cephalosporin — First-generation oral cephalosporin." + }, + { + "label": "Route / Formulation", + "value": "Capsules (250 mg, 500 mg). Oral liquid (125 mg/5mL, 250 mg/5mL). (Keflex, Rilexine)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 500 mg **QID**. Max **4 g/day**." + }, + { + "label": "Key Indication Doses", + "value": "Cellulitis / Skin Infection: **PO** 500 mg **QID**. Uncomplicated UTI: **PO** 500 mg **BD** for 5 days. Renal Impairment: Max 500 mg **BD** if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Cephalexin is a safe, well-tolerated first-generation cephalosporin for skin and simple UTIs, but has limited gram-negative coverage and ~2% cross-reactivity in penicillin allergy." + }, + { + "label": "Avoid / Cautions", + "value": "Cephalosporin anaphylaxis. Avoid in severe immediate (IgE) Penicillin allergy (e.g., hives/anaphylaxis). Safe to use if penicillin allergy is just a mild childhood rash. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea, diarrhea, mild C. diff risk. Immunological: Hypersensitivity rash, rare anaphylaxis. Renal: Interstitial nephritis." + }, + { + "label": "Key Interactions", + "value": "Generally free of major liver/CYP interactions." + }, + { + "label": "Monitoring", + "value": "Check **eGFR** if using high doses (**QID**) in the elderly." + }, + { + "label": "Clinical Pearl", + "value": "Cephalexin has a very short half-life (1 hour). For a tissue infection like cellulitis, dosing it **QID** (every 6 hours) is mandatory to maintain blood levels. Dosing it BD for skin guarantees clinical failure." + } + ] + }, + { + "slug": "ciprofloxacin", + "name": "Ciprofloxacin", + "class": "Antibiotic", + "subclass": "Fluoroquinolone", + "category": "Infectious Diseases - Fluoroquinolones", + "accent": "#ea580c", + "tag": "FLUOROQUINOLONE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1500 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4 h", + "cls": "", + "flag": "" + }, + { + "label": "Tendon Rupture", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Aortic Dissect", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent fluoroquinolone. Exceptional tissue penetration and Gram-negative coverage (including Pseudomonas). Oral absorption is functionally equivalent to IV.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1500 mg/day** (For severe Pseudomonas infections).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Carries 'Black Box' warnings for tendon rupture, aortic aneurysm dissection, and permanent peripheral neuropathy. Do not use for simple infections.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ciprofloxacin is a powerful fluoroquinolone for gram-negative and pseudomonal infections, but carries serious risks of tendon rupture, QTc prolongation, and is restricted due to resistance concerns.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Musculoskeletal", + "val": "CRITICAL — Achilles tendon rupture (can occur suddenly and bilaterally). Exacerbates Myasthenia Gravis.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CRITICAL — Aortic aneurysm dissection/rupture (degrades collagen). HIGH — **QTc** prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "HIGH — Irreversible peripheral neuropathy, seizures (lowers threshold), severe insomnia/anxiety.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — C. difficile infection.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe UTI / Pyelonephritis", + "val": "**PO** 500 mg **BD**.", + "tags": [] + }, + { + "key": "Pseudomonas / Osteomyelitis", + "val": "**PO** 750 mg **BD** OR **IV** 400 mg q8h.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce dose by 50% if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Ciproxin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (250 mg, 500 mg, 750 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-mixed infusion bags for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) to prevent resistance.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Complicated UTIs, Pseudomonas aeruginosa infections, severe Gram-negative osteomyelitis, prostatitis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Reserved exclusively for resistant Gram-negative infections or when an oral anti-pseudomonal agent is required for discharge.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of tendon disorders, known aortic aneurysm, Myasthenia Gravis, prolonged QTc.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy / Paeds", + "val": "CAUTION — **Pregnancy** Category B3; avoid routine use in pregnancy or children/adolescents unless the indication requires ciprofloxacin and benefits outweigh risks.", + "tags": [], + "patient": { + "factors": ["pregnancy", "paediatric"], + "action": "caution", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Ciprofloxacin pregnancy/paediatric row is a source-backed benefit-risk caution rather than an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Dairy, Calcium, Iron, Antacids. Multi-valent cations bind ciprofloxacin in the gut, dropping absorption to zero. Separate by 2-4 hours.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — NSAIDs (massively increases risk of seizures). Corticosteroids (exponentially increases risk of tendon rupture).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn the patient to stop the drug instantly if they feel any pain or snapping in their Achilles tendon or sudden severe chest/back pain.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** to guide dosing.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Bioavailability Flex", + "val": "Ciprofloxacin PO is virtually 100% bioavailable. If a patient is stable with a functioning gut, there is zero clinical reason to use IV Ciprofloxacin. Switch to PO to save their veins and reduce infection risk.", + "tags": [] + }, + { + "key": "The Steroid Trap", + "val": "Giving Ciprofloxacin to an elderly patient who is also taking oral Prednisolone is a classic setup for bilateral Achilles tendon rupture. Avoid this combination.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits bacterial DNA gyrase (Topoisomerase II) and Topoisomerase IV, completely shattering bacterial DNA during replication. Highly bactericidal.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "4 hours (Concentrates massively in urine, prostate, and bone).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CIPROFLOXACIN-BL ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Fluoroquinolone — Highly potent fluoroquinolone." + }, + { + "label": "Route / Formulation", + "value": "Tablets (250 mg, 500 mg, 750 mg). (Ciproxin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 500 mg **BD**. Max **1500 mg/day** (For severe Pseudomonas infections)." + }, + { + "label": "Key Indication Doses", + "value": "Severe UTI / Pyelonephritis: **PO** 500 mg **BD**. Pseudomonas / Osteomyelitis: **PO** 750 mg **BD** OR **IV** 400 mg q8h. Renal Impairment: Reduce dose by 50% if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Ciprofloxacin is a powerful fluoroquinolone for gram-negative and pseudomonal infections, but carries serious risks of tendon rupture, QTc prolongation, and is restricted due to resistance concerns." + }, + { + "label": "Avoid / Cautions", + "value": "History of tendon disorders, known aortic aneurysm, Myasthenia Gravis, prolonged QTc." + }, + { + "label": "Key Risks", + "value": "Musculoskeletal: Achilles tendon rupture (can occur suddenly and bilaterally). Exacerbates Myasthenia Gravis. Cardiovascular: Aortic aneurysm dissection/rupture (degrades collagen). HIGH — **QTc** prolongation. Neurological: Irreversible peripheral neuropathy, seizures (lowers threshold), severe insomnia/anxiety. Gastrointestinal: C. difficile infection." + }, + { + "label": "Key Interactions", + "value": "Dairy, Calcium, Iron, Antacids. Multi-valent cations bind ciprofloxacin in the gut, dropping absorption to zero. Separate by 2-4 hours. NSAIDs (massively increases risk of seizures). Corticosteroids (exponentially increases risk of tendon rupture)." + }, + { + "label": "Monitoring", + "value": "Warn the patient to stop the drug instantly if they feel any pain or snapping in their Achilles tendon or sudden severe chest/back pain. Check **eGFR** to guide dosing." + }, + { + "label": "Clinical Pearl", + "value": "Ciprofloxacin PO is virtually 100% bioavailable. If a patient is stable with a functioning gut, there is zero clinical reason to use IV Ciprofloxacin. Switch to PO to save their veins and reduce infection risk." + } + ] + }, + { + "slug": "vancomycin", + "name": "Vancomycin", + "class": "Antibiotic", + "subclass": "Glycopeptide", + "category": "Infectious Diseases - Glycopeptides", + "accent": "#ea580c", + "tag": "GLYCOPEPTIDE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "TDM Guided", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4-6 h", + "cls": "", + "flag": "" + }, + { + "label": "Red Man", + "value": "INFUSION RATE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Nephrotoxic", + "value": "HIGH RISK", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Massive glycopeptide antibiotic. The heavy artillery for Methicillin-Resistant S. aureus (MRSA) and severe systemic Gram-positive infections.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated strictly via Therapeutic Drug Monitoring (TDM). Loading doses often 25-30 mg/kg.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Too much kills the kidneys; too little breeds resistance. Trough monitoring is absolutely mandatory.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Vancomycin is the last-line glycopeptide for MRSA and serious gram-positive infections, but requires therapeutic drug monitoring (trough levels) and carries nephrotoxicity and Red Man Syndrome risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal", + "val": "HIGH — Nephrotoxicity (Acute Tubular Necrosis), especially if trough levels > 20 mg/L or if combined with other nephrotoxins.", + "tags": [] + }, + { + "key": "Immunological", + "val": "HIGH — 'Red Man Syndrome' or Vancomycin Infusion Reaction (Flushing, severe hypotension, erythema of face/neck due to massive histamine release).", + "tags": [] + }, + { + "key": "Otic", + "val": "LOW — Ototoxicity (Rare unless combined with aminoglycosides).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Systemic MRSA", + "val": "**IV** 15-20 mg/kg (actual body weight) q12h. Loading dose of 25-30 mg/kg in critical illness.", + "tags": [] + }, + { + "key": "C. Difficile Colitis", + "val": "**PO** 125 mg **QID** for 10 days. (Oral Vanc is NOT absorbed systemically; it stays in the gut to kill C. diff).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Dose frequency drastically reduced (e.g., q24h, q48h, or post-dialysis only).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Vancocin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (125 mg, 250 mg). IV powder can be reconstituted and swallowed for C. diff.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply. Restricted.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "MRSA bacteremia/endocarditis/pneumonia, severe coagulase-negative staph, C. diff colitis (PO).", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Empiric choice for suspected MRSA or line-infections. Efficacy relies on 'Area Under the Curve' (AUC) over MIC.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Previous severe hypersensitivity.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Vancomycin pregnancy row is Category B2/caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Other nephrotoxic or ototoxic drugs, including aminoglycosides, loop diuretics and NSAIDs, increase toxicity risk; monitor renal function and vancomycin exposure closely.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Aminoglycosides, Loop Diuretics, NSAIDs (additive nephrotoxicity).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **TDM**. Check trough level immediately before the 3rd or 4th dose. Target is usually 15-20 mg/L for severe infections. Daily **U&E** check.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Ensure infusion rate is NEVER faster than 10 mg/minute (e.g., a 1g dose must take at least 100 minutes) to prevent Red Man Syndrome.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Red Man Fix", + "val": "If a patient goes bright red, itchy, and hypotensive during infusion, it is rarely true anaphylaxis. It is histamine release from rapid infusion. Stop the pump, give an antihistamine, wait for symptoms to clear, and restart at half the speed.", + "tags": [] + }, + { + "key": "The Gut Wall", + "val": "Oral Vancomycin does not enter the blood. It cannot treat systemic MRSA. Conversely, IV Vancomycin does not enter the gut lumen. It cannot treat C. diff. You must use the correct route.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds tightly to the D-alanyl-D-alanine terminus of cell wall precursors, halting cell wall synthesis. (Different site to penicillins).", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Half-life", + "val": "4-6 hours (in healthy kidneys). Up to 7+ days in end-stage renal failure.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DBL Vancomycin ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Glycopeptide — Massive glycopeptide antibiotic." + }, + { + "label": "Route / Formulation", + "value": "Capsules (125 mg, 250 mg). IV powder can be reconstituted and swallowed for C. diff. (Vancocin)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 15-20 mg/kg (actual body weight) q12h. Loading dose of 25-30 mg/kg in critical illness. Titrated strictly via Therapeutic Drug Monitoring (TDM). Loading doses often 25-30 mg/kg." + }, + { + "label": "Key Indication Doses", + "value": "Severe Systemic MRSA: **IV** 15-20 mg/kg (actual body weight) q12h. Loading dose of 25-30 mg/kg in critical illness. C. Difficile Colitis: **PO** 125 mg **QID** for 10 days. (Oral Vanc is NOT absorbed systemically; it stays in the gut to kill C. diff). Renal Impairment: Dose frequency drastically reduced (e.g., q24h, q48h, or post-dialysis only)." + }, + { + "label": "Best Uses", + "value": "Vancomycin is the last-line glycopeptide for MRSA and serious gram-positive infections, but requires therapeutic drug monitoring (trough levels) and carries nephrotoxicity and Red Man Syndrome risk." + }, + { + "label": "Avoid / Cautions", + "value": "Previous severe hypersensitivity. **Pregnancy** Category B2." + }, + { + "label": "Key Risks", + "value": "Renal: Nephrotoxicity (Acute Tubular Necrosis), especially if trough levels > 20 mg/L or if combined with other nephrotoxins. Immunological: 'Red Man Syndrome' or Vancomycin Infusion Reaction (Flushing, severe hypotension, erythema of face/neck due to massive histamine release). Otic: Ototoxicity (Rare unless combined with aminoglycosides)." + }, + { + "label": "Key Interactions", + "value": "Tazocin (Piperacillin/tazobactam). The combination results in a terrifyingly high rate of Acute Kidney Injury. Monitor creatinine daily. Aminoglycosides, Loop Diuretics, NSAIDs (additive nephrotoxicity)." + }, + { + "label": "Monitoring", + "value": "**TDM**. Check trough level immediately before the 3rd or 4th dose. Target is usually 15-20 mg/L for severe infections. Daily **U&E** check. Ensure infusion rate is NEVER faster than 10 mg/minute (e.g., a 1g dose must take at least 100 minutes) to prevent Red Man Syndrome." + }, + { + "label": "Clinical Pearl", + "value": "If a patient goes bright red, itchy, and hypotensive during infusion, it is rarely true anaphylaxis. It is histamine release from rapid infusion. Stop the pump, give an antihistamine, wait for symptoms to clear, and restart at half the speed." + } + ] + }, + { + "slug": "azithromycin", + "name": "Azithromycin", + "class": "Antibiotic", + "subclass": "Macrolide", + "category": "Infectious Diseases - Macrolides", + "accent": "#ea580c", + "tag": "MACROLIDE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "500 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "68 h", + "cls": "", + "flag": "" + }, + { + "label": "QTc Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "CYP3A4", + "value": "WEAK", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Unique macrolide that rapidly leaves the blood and concentrates massively inside phagocytes and tissues. Delivers localized therapy for days after the last dose.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **500 mg/day** (or 1g single STAT dose for STIs).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Known to prolong the QTc interval. However, it lacks the severe CYP3A4 drug interactions seen with Clarithromycin.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Azithromycin is a convenient 3-5 day macrolide for atypical pneumonia, STIs, and penicillin-allergic patients, but prolongs QTc and has significant drug interactions via CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — **QTc** prolongation, potentially leading to Torsades de Pointes/VF.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, severe abdominal cramping, diarrhea (due to motilin receptor agonism).", + "tags": [] + }, + { + "key": "Otic", + "val": "MODERATE — Reversible hearing loss (with prolonged high-dose use).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Community Acquired Pneumonia", + "val": "**PO** / **IV** 500 mg **OD** for 3 days.", + "tags": [] + }, + { + "key": "Chlamydia Trachomatis", + "val": "**PO** 1 g STAT.", + "tags": [] + }, + { + "key": "COPD Exacerbation Prophylaxis", + "val": "**PO** 250 mg 3 times a week (Specialist off-label).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zithromax", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (500 mg). Oral liquid.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (500 mg) for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Atypical pneumonia (Legionella, Mycoplasma), Chlamydia, Pertussis, severe Campylobacter.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Prokinetic for severe gastroparesis (IV). Chronic inflammation reduction in COPD.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "First-line empirical addition to Ceftriaxone for severe CAP to cover 'atypicals'.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Baseline **QTc** > 500 ms, history of macrolide hypersensitivity, or history of macrolide-associated cholestatic jaundice/hepatic dysfunction.", + "tags": [], + "patient": { + "factors": ["qtc", "allergy-macrolide", "hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 500 + } + }, + "note": "Azithromycin requires avoidance/review with marked QTc prolongation, macrolide hypersensitivity, or previous macrolide-associated hepatic dysfunction." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1. The safest macrolide in pregnancy.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Azithromycin pregnancy row is Category B1/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Unlike Clarithromycin and Erythromycin, Azithromycin does NOT significantly inhibit CYP3A4. It is much safer to use alongside statins and DOACs.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive QTc prolongation with Amiodarone, Haloperidol, Sotalol, Ondansetron.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG** before giving IV or prescribing to elderly patients on multiple cardiac meds.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Laboratory", + "val": "Check **U&E** to ensure potassium and magnesium are normal to prevent arrhythmias.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Prokinetic Hack", + "val": "Because it binds to motilin receptors in the gut, IV Azithromycin (250mg) is sometimes used in the ICU as a highly potent prokinetic to force gastric emptying when a patient's bowels have completely stalled.", + "tags": [] + }, + { + "key": "The Post-Dose Effect", + "val": "Explain to patients that a 3-day script of Azithromycin is actually a 10-day treatment course. The drug stays in the lung tissue long after the pills are gone.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to the 50S ribosomal subunit, halting bacterial protein synthesis. Concentrates in macrophages, which carry the drug directly to the site of infection.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** Hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "Therapeutic tissue levels last for up to 7 days after a 3-day course.", + "tags": [] + }, + { + "key": "Half-life", + "val": "68 hours (Massive volume of distribution).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ZITHROMAX azithromycin ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Macrolide — Unique macrolide that rapidly leaves the blood and concentrates massively inside phagocytes and tissues." + }, + { + "label": "Route / Formulation", + "value": "Tablets (500 mg). Oral liquid. (Zithromax)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** / **IV** 500 mg **OD** for 3 days. Max **500 mg/day** (or 1g single STAT dose for STIs)." + }, + { + "label": "Key Indication Doses", + "value": "Community Acquired Pneumonia: **PO** / **IV** 500 mg **OD** for 3 days. Chlamydia Trachomatis: **PO** 1 g STAT. COPD Exacerbation Prophylaxis: **PO** 250 mg 3 times a week (Specialist off-label)." + }, + { + "label": "Best Uses", + "value": "Azithromycin is a convenient 3-5 day macrolide for atypical pneumonia, STIs, and penicillin-allergic patients, but prolongs QTc and has significant drug interactions via CYP3A4." + }, + { + "label": "Avoid / Cautions", + "value": "Baseline **QTc** > 500 ms, history of macrolide-induced cholestatic jaundice. **Pregnancy** Category B1. The safest macrolide in pregnancy." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: **QTc** prolongation, potentially leading to Torsades de Pointes/VF. Gastrointestinal: Nausea, severe abdominal cramping, diarrhea (due to motilin receptor agonism). Otic: Reversible hearing loss (with prolonged high-dose use)." + }, + { + "label": "Key Interactions", + "value": "Unlike Clarithromycin and Erythromycin, Azithromycin does NOT significantly inhibit CYP3A4. It is much safer to use alongside statins and DOACs. Additive QTc prolongation with Amiodarone, Haloperidol, Sotalol, Ondansetron." + }, + { + "label": "Monitoring", + "value": "Baseline **ECG** before giving IV or prescribing to elderly patients on multiple cardiac meds. Check **U&E** to ensure potassium and magnesium are normal to prevent arrhythmias." + }, + { + "label": "Clinical Pearl", + "value": "Because it binds to motilin receptors in the gut, IV Azithromycin (250mg) is sometimes used in the ICU as a highly potent prokinetic to force gastric emptying when a patient's bowels have completely stalled." + } + ] + }, + { + "slug": "clarithromycin", + "name": "Clarithromycin", + "class": "Antibiotic", + "subclass": "Macrolide", + "category": "Infectious Diseases - Macrolides", + "accent": "#ea580c", + "tag": "MACROLIDE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1000 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5-7 h", + "cls": "", + "flag": "" + }, + { + "label": "CYP Inhibitor", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Metallic Taste", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent macrolide. Exceptional coverage for atypical pneumonias and H. pylori. However, it is one of the most dangerous inhibitors of liver enzymes in modern medicine.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1000 mg/day** (e.g., 500 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Completely shuts down CYP3A4. Co-administration with Statins, DOACs, or Colchicine causes fatal multi-organ toxicity.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Clarithromycin is a macrolide for respiratory infections and H. pylori eradication, but is a potent CYP3A4 inhibitor with significant drug interactions and QTc prolongation risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — **QTc** prolongation, risk of Torsades de Pointes and sudden cardiac death (especially in the elderly).", + "tags": [], + "patient": { + "factors": ["elderly", "qtc"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + }, + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe bitter/metallic taste in the mouth (dysgeusia), nausea, diarrhea.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "MODERATE — Hepatotoxicity, jaundice.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Community Acquired Pneumonia", + "val": "**PO** 250-500 mg **BD** for 5-7 days.", + "tags": [] + }, + { + "key": "H. Pylori Eradication", + "val": "**PO** 500 mg **BD** (with Amoxicillin and a PPI).", + "tags": [] + }, + { + "key": "MAC (Mycobacterium avium)", + "val": "**PO** 500 mg **BD** (Long term, specialist only).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Halve the dose if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Klacid, Clarac", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (250 mg, 500 mg). Oral liquid.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for specific indications.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Atypical CAP, H. pylori eradication, severe MAC complex in HIV.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Preferred over erythromycin due to BD dosing and better GI tolerance. Highly effective but dangerous due to interactions.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Contraindicated with high-risk CYP3A4/P-gp substrates such as colchicine, ergotamines, some statins, ticagrelor, and with marked baseline **QTc** prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 500 + } + }, + "note": "Clarithromycin requires avoidance/review with marked QTc prolongation and high-risk interacting medicines." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3 (Azithromycin is preferred).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Clarithromycin pregnancy row is Category B3/benefit-risk caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Absolute blockade of **CYP3A4** and **P-glycoprotein**. Causes Atorvastatin to trigger rhabdomyolysis, Colchicine to cause fatal bone marrow failure, and Apixaban/Rivaroxaban to cause major bleeding. You MUST withhold these drugs while the patient is on Clarithromycin.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Synergistic QTc prolongation with Amiodarone, Haloperidol, Sotalol.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Review the patient's entire medication list through a drug-interaction checker before prescribing.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Baseline **ECG** for high-risk patients.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Statin Rule", + "val": "If a patient on 80mg Atorvastatin gets pneumonia and needs Clarithromycin, physically cross the Statin off the drug chart for the 7-day course. Missing a week of statin will not cause a heart attack; mixing them will cause fatal rhabdomyolysis.", + "tags": [] + }, + { + "key": "The Taste Warning", + "val": "Warn patients about the metallic taste. It is secreted into the saliva, so food/water does not wash it away. It resolves when the drug is ceased.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds the 50S ribosomal subunit, halting bacterial protein synthesis. Bacteriostatic (but bactericidal against H. pylori).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5-7 hours. Extensively metabolised by CYP3A4, producing an active metabolite (14-OH-clarithromycin).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - NOUMED CLARITHROMYCIN ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Macrolide — Highly potent macrolide." + }, + { + "label": "Route / Formulation", + "value": "Tablets (250 mg, 500 mg). Oral liquid. (Klacid, Clarac)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 250-500 mg **BD** for 5-7 days. Max **1000 mg/day** (e.g., 500 mg BD)." + }, + { + "label": "Key Indication Doses", + "value": "Community Acquired Pneumonia: **PO** 250-500 mg **BD** for 5-7 days. H. Pylori Eradication: **PO** 500 mg **BD** (with Amoxicillin and a PPI). MAC (Mycobacterium avium): **PO** 500 mg **BD** (Long term, specialist only). Renal Impairment: Halve the dose if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Clarithromycin is a macrolide for respiratory infections and H. pylori eradication, but is a potent CYP3A4 inhibitor with significant drug interactions and QTc prolongation risk." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of Colchicine, Statins (Simvastatin/Atorvastatin), Ticagrelor, or Ergotamines. Baseline **QTc** > 500 ms. **Pregnancy** Category B3 (Azithromycin is preferred)." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: **QTc** prolongation, risk of Torsades de Pointes and sudden cardiac death (especially in the elderly). Gastrointestinal: Severe bitter/metallic taste in the mouth (dysgeusia), nausea, diarrhea. Hepatic: Hepatotoxicity, jaundice." + }, + { + "label": "Key Interactions", + "value": "Absolute blockade of **CYP3A4** and **P-glycoprotein**. Causes Atorvastatin to trigger rhabdomyolysis, Colchicine to cause fatal bone marrow failure, and Apixaban/Rivaroxaban to cause major bleeding. You MUST withhold these drugs while the patient is on Clarithromycin. Synergistic QTc prolongation with Amiodarone, Haloperidol, Sotalol." + }, + { + "label": "Monitoring", + "value": "Review the patient's entire medication list through a drug-interaction checker before prescribing. Baseline **ECG** for high-risk patients." + }, + { + "label": "Clinical Pearl", + "value": "If a patient on 80mg Atorvastatin gets pneumonia and needs Clarithromycin, physically cross the Statin off the drug chart for the 7-day course. Missing a week of statin will not cause a heart attack; mixing them will cause fatal rhabdomyolysis." + } + ] + }, + { + "slug": "erythromycin", + "name": "Erythromycin", + "class": "Antibiotic", + "subclass": "Macrolide", + "category": "Infectious Diseases - Macrolides", + "accent": "#ea580c", + "tag": "MACROLIDE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "4 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1.5 h", + "cls": "", + "flag": "" + }, + { + "label": "GI Upset", + "value": "SEVERE", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Prokinetic", + "value": "OFF-LABEL", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The original macrolide antibiotic. Due to its short half-life, severe GI toxicity, and massive drug interactions, it is largely obsolete as an antibiotic. Now heavily utilized as an IV prokinetic to force gastric emptying.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 g/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Like Clarithromycin, it is a potent CYP3A4 inhibitor. Causes agonizing stomach cramps by massively stimulating gut motilin receptors.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Erythromycin is a macrolide useful for respiratory infections and as a prokinetic agent, but causes significant GI disturbance and has extensive CYP3A4 drug interactions.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Severe abdominal cramping, nausea, vomiting, diarrhea. (This 'side effect' is the main reason we use it).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — **QTc** prolongation, ventricular arrhythmias, thrombophlebitis via IV route.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Hepatic", + "val": "MODERATE — Cholestatic jaundice (historically associated with the estolate salt formulation).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Gastroparesis / Pre-Endoscopy (Off-Label)", + "val": "**IV** 250 mg STAT or QID (Run over 20-30 mins to avoid cardiac toxicity). Forces the stomach to empty.", + "tags": [] + }, + { + "key": "Infection (Rarely used)", + "val": "**PO** 250-500 mg **QID** (Strictly before food).", + "tags": [] + }, + { + "key": "Neonatal Chlamydia", + "val": "**PO** Specialist weight-based dosing.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Eryc, EES", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets (250 mg, 400 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (1 g powder) for **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Penicillin-allergic patients with susceptible infections.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Gastroparesis, clearing blood from the stomach prior to an urgent endoscopy for a GI bleed.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Almost entirely replaced by Azithromycin and Clarithromycin for infections. Survives in hospitals entirely as a GI motility agent.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent high-risk CYP3A4 substrates such as colchicine, ergot derivatives or selected statins, and marked baseline **QTc** prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 500 + } + }, + "note": "Erythromycin requires avoidance/review with marked QTc prolongation and high-risk interacting medicines." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A; neonatal exposure in the first weeks of life has been associated with infantile hypertrophic pyloric stenosis, so use neonatal courses only with appropriate indication and monitoring.", + "tags": [], + "patient": { + "factors": ["pregnancy", "paediatric"], + "action": "caution", + "severity": "caution", + "match": { + "age": { + "lt": 0.08 + } + }, + "note": "Erythromycin pregnancy is Category A, but early neonatal courses need indication-specific monitoring." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Shuts down **CYP3A4**. Fatal interactions with Simvastatin/Atorvastatin (rhabdomyolysis), Colchicine, and Warfarin.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — **ECG** monitoring. Do not push IV fast; must be infused to prevent sudden QTc spikes and arrhythmias.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Endoscopy Flush", + "val": "If a patient has a massive upper GI bleed, the stomach fills with blood clots, making it impossible for the endoscopist to see the bleeding ulcer. A 250mg dose of IV Erythromycin given 30 minutes before the scope causes the stomach to violently violently empty the clots into the duodenum, providing a clear camera view.", + "tags": [] + }, + { + "key": "The Rapid Tolerance", + "val": "When used as a prokinetic for chronic gastroparesis, the motilin receptors downregulate rapidly. The drug completely loses its prokinetic effect after 2-4 weeks of use.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds 50S ribosomal subunit. As a prokinetic, it is a direct, potent agonist of the 'motilin' receptor in the gut, triggering the migrating motor complex and violently forcing gastric emptying.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 15-30 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1.5 hours. Excreted primarily in bile/feces.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - E-MYCIN/ERYC erythromycin ARTG/PI/CMI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Macrolide — The original macrolide antibiotic." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets (250 mg, 400 mg). (Eryc, EES)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 250 mg STAT or QID (Run over 20-30 mins to avoid cardiac toxicity). Forces the stomach to empty. Max **4 g/day**." + }, + { + "label": "Key Indication Doses", + "value": "Gastroparesis / Pre-Endoscopy (Off-Label): **IV** 250 mg STAT or QID (Run over 20-30 mins to avoid cardiac toxicity). Forces the stomach to empty. Infection (Rarely used): **PO** 250-500 mg **QID** (Strictly before food). Neonatal Chlamydia: **PO** Specialist weight-based dosing." + }, + { + "label": "Best Uses", + "value": "Erythromycin is a macrolide useful for respiratory infections and as a prokinetic agent, but causes significant GI disturbance and has extensive CYP3A4 drug interactions." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of potent CYP3A4 substrates (Colchicine, Statins). Baseline **QTc** > 500 ms. **Pregnancy** Category A, BUT associated with Infantile Hypertrophic Pyloric Stenosis if given to neonates in the first 2 weeks of life." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe abdominal cramping, nausea, vomiting, diarrhea. (This 'side effect' is the main reason we use it). Cardiovascular: **QTc** prolongation, ventricular arrhythmias, thrombophlebitis via IV route. Hepatic: Cholestatic jaundice (historically associated with the estolate salt formulation)." + }, + { + "label": "Key Interactions", + "value": "Shuts down **CYP3A4**. Fatal interactions with Simvastatin/Atorvastatin (rhabdomyolysis), Colchicine, and Warfarin." + }, + { + "label": "Monitoring", + "value": "**ECG** monitoring. Do not push IV fast; must be infused to prevent sudden QTc spikes and arrhythmias." + }, + { + "label": "Clinical Pearl", + "value": "If a patient has a massive upper GI bleed, the stomach fills with blood clots, making it impossible for the endoscopist to see the bleeding ulcer. A 250mg dose of IV Erythromycin given 30 minutes before the scope causes the stomach to violently violently empty the clots into the duodenum, providing a clear camera view." + } + ] + }, + { + "slug": "minocycline", + "name": "Minocycline", + "class": "Antibiotic", + "subclass": "Tetracycline", + "category": "Infectious Diseases - Macrolides & Tetracyclines", + "accent": "#ea580c", + "tag": "TETRACYCLINE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "200 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "15 h", + "cls": "", + "flag": "" + }, + { + "label": "Vestibular Tox", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Pigmentation", + "value": "CHRONIC RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly lipophilic, broad-spectrum bacteriostatic tetracycline. Exceptional tissue penetration. Primarily used for severe, scarring acne and certain MRSA/atypical infections.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **200 mg/day** (Usually 50-100 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Unique among tetracyclines for causing severe vestibular toxicity (vertigo/dizziness) and irreversible blue-grey skin pigmentation with chronic use.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Minocycline is a tetracycline used for acne and some resistant infections, but causes vestibular toxicity (dizziness), blue-grey skin discolouration, and drug-induced lupus.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Vestibular toxicity (severe vertigo, dizziness, ataxia) occurring in up to 20% of women. Benign intracranial hypertension (pseudotumor cerebri).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "HIGH — Blue-grey hyperpigmentation of the skin, nails, and scars (can be permanent). Drug-induced lupus erythematosus (DILE).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea, pill esophagitis (less than Doxycycline).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Acne Vulgaris", + "val": "**PO** 50 mg **BD** (taken with food/milk to reduce nausea, unlike older tetracyclines).", + "tags": [] + }, + { + "key": "MRSA Skin Infections", + "val": "**PO** 100 mg **BD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Minomycin, Akamin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets (50 mg, 100 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Moderate to severe acne vulgaris, susceptible MRSA infections, Nocardia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Often chosen when Doxycycline fails for acne, but limited by its heavier side effect profile.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Children < 8 years (permanent tooth staining/bone effects) and concurrent retinoids such as isotretinoin due to intracranial hypertension risk.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 8 + } + }, + "note": "Minocycline is contraindicated/avoided in children younger than 8 years because of tooth and bone effects." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D (impairs fetal bone growth).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Chelates with Iron, Calcium, and Antacids. Separate by 2 hours.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Oral Retinoids (Isotretinoin/Roaccutane). Fatal interaction causing pseudotumor cerebri.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn the patient to stop the drug if they experience severe unexplained headaches and blurred vision (signs of increased intracranial pressure).", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor **LFTs** and ANA levels if used chronically (Lupus risk).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Blue Scar", + "val": "Minocycline deposits in melanin and collagen. Patients on long-term therapy for acne can suddenly develop a muddy, blue-grey discoloration in their old acne scars or on their shins. It takes years to fade once the drug is stopped.", + "tags": [] + }, + { + "key": "The Dairy Exception", + "val": "Unlike standard tetracycline, Minocycline absorption is NOT significantly impaired by dairy. It can be taken with milk to reduce nausea.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to the 30S ribosomal subunit, preventing the addition of amino acids and halting bacterial protein synthesis. Highly lipophilic, penetrating the blood-brain barrier easily.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "15 hours. Extensively hepatically metabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - MINOMYCIN minocycline ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Tetracycline — Highly lipophilic, broad-spectrum bacteriostatic tetracycline." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets (50 mg, 100 mg). (Minomycin, Akamin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 50 mg **BD** (taken with food/milk to reduce nausea, unlike older tetracyclines). Max **200 mg/day** (Usually 50-100 mg BD)." + }, + { + "label": "Key Indication Doses", + "value": "Severe Acne Vulgaris: **PO** 50 mg **BD** (taken with food/milk to reduce nausea, unlike older tetracyclines). MRSA Skin Infections: **PO** 100 mg **BD**." + }, + { + "label": "Best Uses", + "value": "Minocycline is a tetracycline used for acne and some resistant infections, but causes vestibular toxicity (dizziness), blue-grey skin discolouration, and drug-induced lupus." + }, + { + "label": "Avoid / Cautions", + "value": "Children < 8 years (permanent tooth staining), concurrent use with Isotretinoin (massive risk of intracranial hypertension). **Pregnancy** Category D (impairs fetal bone growth)." + }, + { + "label": "Key Risks", + "value": "Neurological: Vestibular toxicity (severe vertigo, dizziness, ataxia) occurring in up to 20% of women. Benign intracranial hypertension (pseudotumor cerebri). Dermatological: Blue-grey hyperpigmentation of the skin, nails, and scars (can be permanent). Drug-induced lupus erythematosus (DILE). Gastrointestinal: Nausea, pill esophagitis (less than Doxycycline)." + }, + { + "label": "Key Interactions", + "value": "Chelates with Iron, Calcium, and Antacids. Separate by 2 hours. Oral Retinoids (Isotretinoin/Roaccutane). Fatal interaction causing pseudotumor cerebri." + }, + { + "label": "Monitoring", + "value": "Warn the patient to stop the drug if they experience severe unexplained headaches and blurred vision (signs of increased intracranial pressure). Monitor **LFTs** and ANA levels if used chronically (Lupus risk)." + }, + { + "label": "Clinical Pearl", + "value": "Minocycline deposits in melanin and collagen. Patients on long-term therapy for acne can suddenly develop a muddy, blue-grey discoloration in their old acne scars or on their shins. It takes years to fade once the drug is stopped." + } + ] + }, + { + "slug": "roxithromycin", + "name": "Roxithromycin", + "class": "Antibiotic", + "subclass": "Macrolide", + "category": "Infectious Diseases - Macrolides & Tetracyclines", + "accent": "#ea580c", + "tag": "MACROLIDE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10 h", + "cls": "", + "flag": "" + }, + { + "label": "GI Upset", + "value": "LESS THAN ERY", + "cls": "good", + "flag": "" + }, + { + "label": "CYP Inhibitor", + "value": "WEAK", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Semi-synthetic macrolide. Designed to provide the atypical coverage of Erythromycin without the horrific GI cramps and severe CYP3A4 drug interactions.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg/day** (e.g., 150 mg BD or 300 mg OD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Significantly safer to co-prescribe with Statins and Warfarin compared to Clarithromycin, making it highly useful in the elderly.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Roxithromycin is a macrolide antibiotic for respiratory and soft tissue infections with better GI tolerability than erythromycin, but still carries QTc prolongation and drug interaction risks.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea, abdominal pain (significantly less severe than Erythromycin because it does not bind motilin receptors).", + "tags": [], + "patient": { + "factors": ["allergy-macrolide"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Cardiovascular", + "val": "MODERATE — **QTc** prolongation (inherent to all macrolides, but less pronounced).", + "tags": [], + "patient": { + "factors": ["qtc", "allergy-macrolide"], + "action": "caution", + "severity": "danger", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Hepatic", + "val": "LOW — Transient transaminitis.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Atypical CAP / Mild Skin Infections", + "val": "**PO** 150 mg **BD** OR 300 mg **OD**. Best taken 15 mins before food to maximize absorption.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "SAFE — No strict dose reduction required in mild/moderate CKD (Hepatically cleared).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Rulide, Biaxin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (150 mg, 300 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Community-acquired pneumonia, acute bronchitis, non-gonococcal urethritis, skin infections in penicillin-allergic patients.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "A safer, highly tolerable alternative to Clarithromycin/Erythromycin in primary care.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Contraindicated with ergotamine/dihydroergotamine derivatives and avoid/review with marked baseline **QTc** prolongation or major QT-prolonging combinations.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 500 + } + }, + "note": "Roxithromycin requires avoidance/review with marked QTc prolongation or major QT-prolonging combinations." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Roxithromycin pregnancy row is Category B1/benefit-risk caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — It has very low affinity for CYP3A4 compared to Clarithromycin. It does not significantly spike levels of Atorvastatin, Warfarin, or DOACs, making it the macrolide of choice in polypharmacy.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "Consider **ECG** if combining with other QTc prolonging drugs.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Statin Safe-Haven", + "val": "If an elderly patient is on 80mg Atorvastatin and develops a Mycoplasma pneumonia, giving them Clarithromycin will cause rhabdomyolysis. Switching the script to Roxithromycin avoids the interaction entirely and keeps the patient safe.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds the 50S ribosomal subunit, halting bacterial protein synthesis. Bacteriostatic.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10-12 hours. Primarily eliminated via feces/bile.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ROXITHROMYCIN SANDOZ ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Macrolide — Semi-synthetic macrolide." + }, + { + "label": "Route / Formulation", + "value": "Tablets (150 mg, 300 mg). (Rulide, Biaxin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 150 mg **BD** OR 300 mg **OD**. Best taken 15 mins before food to maximize absorption. Max **300 mg/day** (e.g., 150 mg BD or 300 mg OD)." + }, + { + "label": "Key Indication Doses", + "value": "Atypical CAP / Mild Skin Infections: **PO** 150 mg **BD** OR 300 mg **OD**. Best taken 15 mins before food to maximize absorption. Renal Impairment: No strict dose reduction required in mild/moderate CKD (Hepatically cleared)." + }, + { + "label": "Best Uses", + "value": "Roxithromycin is a macrolide antibiotic for respiratory and soft tissue infections with better GI tolerability than erythromycin, but still carries QTc prolongation and drug interaction risks." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of ergotamine derivatives. Baseline **QTc** > 500 ms. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea, abdominal pain (significantly less severe than Erythromycin because it does not bind motilin receptors). Cardiovascular: **QTc** prolongation (inherent to all macrolides, but less pronounced). Hepatic: Transient transaminitis." + }, + { + "label": "Key Interactions", + "value": "It has very low affinity for CYP3A4 compared to Clarithromycin. It does not significantly spike levels of Atorvastatin, Warfarin, or DOACs, making it the macrolide of choice in polypharmacy." + }, + { + "label": "Monitoring", + "value": "Consider **ECG** if combining with other QTc prolonging drugs. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "If an elderly patient is on 80mg Atorvastatin and develops a Mycoplasma pneumonia, giving them Clarithromycin will cause rhabdomyolysis. Switching the script to Roxithromycin avoids the interaction entirely and keeps the patient safe." + } + ] + }, + { + "slug": "amikacin", + "name": "Amikacin", + "class": "Antibiotic", + "subclass": "Aminoglycoside", + "category": "Infectious Diseases - Other Antibiotics", + "accent": "#ea580c", + "tag": "AMINOGLYCOSIDE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "15 mg/kg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-3 h", + "cls": "", + "flag": "" + }, + { + "label": "Nephrotoxic", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Ototoxic", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The most robust, heavy-duty aminoglycoside. Exceptionally resistant to bacterial aminoglycoside-modifying enzymes. Reserved exclusively for highly resistant, life-threatening Gram-negative sepsis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **15 mg/kg/day** (strictly based on Ideal Body Weight).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Lethally nephrotoxic and permanently ototoxic (deafness) if trough levels do not fall to zero between doses.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Amikacin is a potent aminoglycoside reserved for multi-resistant gram-negative infections, but has critical nephrotoxicity and irreversible ototoxicity requiring strict therapeutic drug monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal", + "val": "CRITICAL — Acute tubular necrosis (AKI). The risk skyrockets if the drug 'trough' level stays high.", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Irreversible vestibular and cochlear toxicity (permanent deafness and severe vertigo/balance destruction).", + "tags": [] + }, + { + "key": "Neuromuscular", + "val": "HIGH — Neuromuscular blockade (can exacerbate Myasthenia Gravis or surgical paralysis).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Multi-Drug Resistant Sepsis", + "val": "**IV** 15 mg/kg **OD** (Infused over 30 mins).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Increase interval drastically. If **eGFR** 20-40, give dose every 48 hours. If **eGFR** < 20, dose ONLY by tracking serum levels (often every 72+ hours).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Amikin", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules/Vials (500 mg/2 mL) for **IV** or **IM** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply. Strictly governed by Antimicrobial Stewardship.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe nosocomial Gram-negative sepsis (Pseudomonas, Acinetobacter) resistant to Gentamicin. Empiric therapy for severe neutropenic fever.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Last line of defense in the aminoglycoside class. Never used for simple infections.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Myasthenia Gravis, pre-existing hearing loss.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D (Congenital deafness).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Obesity", + "val": "CRITICAL — MUST use Ideal Body Weight (IBW) for dosing. Dosing on actual weight in an obese patient causes a massive, fatal overdose.", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Vancomycin, Loop Diuretics (Frusemide), Cisplatin. Synergistic, catastrophic nephrotoxicity and ototoxicity.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **TDM** (Therapeutic Drug Monitoring). Trough levels MUST be checked before the 2nd dose (Target < 5 mg/L). Daily **U&E** and **eGFR**.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Question the conscious patient daily regarding tinnitus (ringing ears) or dizziness. Stop instantly if present.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Zero Trough", + "val": "Aminoglycosides kill bacteria using the massive 'peak' concentration. They destroy the kidneys if the 'trough' concentration stays high. The kidney tubules need a 12-hour period of 'zero drug' in the blood to wash out and recover. This is why we use massive Once-Daily doses rather than smaller TDS doses.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Irreversibly binds the 30S ribosomal subunit. Highly bactericidal with a prolonged post-antibiotic effect. Its unique side chain protects it from destruction by bacterial enzymes that normally destroy Gentamicin.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate peak.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours. 100% renally cleared unchanged via glomerular filtration.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DBL/EMC Amikacin ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Aminoglycoside — The most robust, heavy-duty aminoglycoside." + }, + { + "label": "Route / Formulation", + "value": "Ampoules/Vials (500 mg/2 mL) for **IV** or **IM** use. (Amikin)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 15 mg/kg **OD** (Infused over 30 mins). Max **15 mg/kg/day** (strictly based on Ideal Body Weight)." + }, + { + "label": "Key Indication Doses", + "value": "Severe Multi-Drug Resistant Sepsis: **IV** 15 mg/kg **OD** (Infused over 30 mins). Renal Impairment: Increase interval drastically. If **eGFR** 20-40, give dose every 48 hours. If **eGFR** < 20, dose ONLY by tracking serum levels (often every 72+ hours)." + }, + { + "label": "Best Uses", + "value": "Amikacin is a potent aminoglycoside reserved for multi-resistant gram-negative infections, but has critical nephrotoxicity and irreversible ototoxicity requiring strict therapeutic drug monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Myasthenia Gravis, pre-existing hearing loss. **Pregnancy** Category D (Congenital deafness)." + }, + { + "label": "Key Risks", + "value": "Renal: Acute tubular necrosis (AKI). The risk skyrockets if the drug 'trough' level stays high. Neurological: Irreversible vestibular and cochlear toxicity (permanent deafness and severe vertigo/balance destruction). Neuromuscular: Neuromuscular blockade (can exacerbate Myasthenia Gravis or surgical paralysis)." + }, + { + "label": "Key Interactions", + "value": "Vancomycin, Loop Diuretics (Frusemide), Cisplatin. Synergistic, catastrophic nephrotoxicity and ototoxicity." + }, + { + "label": "Monitoring", + "value": "**TDM** (Therapeutic Drug Monitoring). Trough levels MUST be checked before the 2nd dose (Target < 5 mg/L). Daily **U&E** and **eGFR**. Question the conscious patient daily regarding tinnitus (ringing ears) or dizziness. Stop instantly if present." + }, + { + "label": "Clinical Pearl", + "value": "Aminoglycosides kill bacteria using the massive 'peak' concentration. They destroy the kidneys if the 'trough' concentration stays high. The kidney tubules need a 12-hour period of 'zero drug' in the blood to wash out and recover. This is why we use massive Once-Daily doses rather than smaller TDS doses." + } + ] + }, + { + "slug": "aztreonam", + "name": "Aztreonam", + "class": "Antibiotic", + "subclass": "Monobactam", + "category": "Infectious Diseases - Other Antibiotics", + "accent": "#ea580c", + "tag": "MONOBACTAM", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "8 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "Penicillin Allergy", + "value": "SAFE", + "cls": "good", + "flag": "" + }, + { + "label": "Gram Positive", + "value": "NO COVER", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The only monobactam antibiotic. Highly specific for aerobic Gram-negative bacteria (including Pseudomonas). Completely ignores Gram-positives and anaerobes.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **8 g/day** (e.g., 2 g q6h for severe Pseudomonas).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Has zero cross-reactivity with penicillin or cephalosporin allergies. The ultimate safe 'big gun' for patients with severe IgE anaphylaxis to beta-lactams.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Aztreonam is a monobactam with pure gram-negative coverage safe in penicillin allergy, but has no gram-positive or anaerobic activity requiring combination therapy for mixed infections.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Immunological", + "val": "SAFE — The unique beta-lactam ring is structurally isolated. It does NOT cross-react with IgE antibodies formed against penicillins.", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Hepatic", + "val": "MODERATE — Transient transaminitis.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Local", + "val": "MODERATE — Phlebitis at IV site.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Gram-Negative Sepsis", + "val": "**IV** 1-2 g q8h.", + "tags": [] + }, + { + "key": "Pseudomonas Sepsis", + "val": "**IV** 2 g q6h to q8h.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Halve the dose if **eGFR** 10-30. Quarter the dose if **eGFR** < 10.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Azactam", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (1 g powder) for **IV** infusion or deep **IM**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply. Restricted by Antimicrobial Stewardship.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe Gram-negative infections (UTI, intra-abdominal, respiratory) in patients with severe penicillin/cephalosporin anaphylaxis.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Replaces Ceftriaxone or Tazocin in patients who will die of anaphylaxis if given a standard beta-lactam.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known specific anaphylaxis to Aztreonam itself. Ceftazidime allergy (shares an identical side chain with Ceftazidime; cross-reaction is possible!).", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "LOW — Extremely clean interaction profile. Synergistic with aminoglycosides against Pseudomonas.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Check **eGFR** for dose adjustment.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Because it provides zero coverage against Staph, Strep, or Anaerobes, it MUST be co-prescribed with Vancomycin and Metronidazole for empiric broad-spectrum coverage in a sick patient.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Ceftazidime Trap", + "val": "Aztreonam is 100% safe in severe penicillin and standard cephalosporin allergies. However, it shares the exact same R1 side-chain as Ceftazidime. If the patient is specifically anaphylactic to Ceftazidime, they WILL react to Aztreonam. Avoid it.", + "tags": [] + }, + { + "key": "The Narrow Sniper", + "val": "Do not use Aztreonam as monotherapy for an undifferentiated septic shock patient. If a Gram-positive bug (like Staph aureus) is causing the sepsis, the Aztreonam will literally bounce off it and the patient will die.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds exclusively to PBP3, which is only present in aerobic Gram-negative bacteria. Halts cell wall synthesis. Highly resistant to metallo-beta-lactamases.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1.5 - 2 hours. Renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - AZACTAM aztreonam ARTG/PI/CMI and PBS check checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Monobactam — The only monobactam antibiotic." + }, + { + "label": "Route / Formulation", + "value": "Vials (1 g powder) for **IV** infusion or deep **IM**. (Azactam)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 1-2 g q8h. Max **8 g/day** (e.g., 2 g q6h for severe Pseudomonas)." + }, + { + "label": "Key Indication Doses", + "value": "Severe Gram-Negative Sepsis: **IV** 1-2 g q8h. Pseudomonas Sepsis: **IV** 2 g q6h to q8h. Renal Impairment: Halve the dose if **eGFR** 10-30. Quarter the dose if **eGFR** < 10." + }, + { + "label": "Best Uses", + "value": "Aztreonam is a monobactam with pure gram-negative coverage safe in penicillin allergy, but has no gram-positive or anaerobic activity requiring combination therapy for mixed infections." + }, + { + "label": "Avoid / Cautions", + "value": "Known specific anaphylaxis to Aztreonam itself. Ceftazidime allergy (shares an identical side chain with Ceftazidime; cross-reaction is possible!). **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Immunological: The unique beta-lactam ring is structurally isolated. It does NOT cross-react with IgE antibodies formed against penicillins. Hepatic: Transient transaminitis. Local: Phlebitis at IV site." + }, + { + "label": "Key Interactions", + "value": "Extremely clean interaction profile. Synergistic with aminoglycosides against Pseudomonas." + }, + { + "label": "Monitoring", + "value": "Check **eGFR** for dose adjustment. Because it provides zero coverage against Staph, Strep, or Anaerobes, it MUST be co-prescribed with Vancomycin and Metronidazole for empiric broad-spectrum coverage in a sick patient." + }, + { + "label": "Clinical Pearl", + "value": "Aztreonam is 100% safe in severe penicillin and standard cephalosporin allergies. However, it shares the exact same R1 side-chain as Ceftazidime. If the patient is specifically anaphylactic to Ceftazidime, they WILL react to Aztreonam. Avoid it." + } + ] + }, + { + "slug": "clindamycin", + "name": "Clindamycin", + "class": "Antibiotic", + "subclass": "Lincosamide", + "category": "Infectious Diseases - Other Antibiotics", + "accent": "#ea580c", + "tag": "LINCOSAMIDE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1.8 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-3 h", + "cls": "", + "flag": "" + }, + { + "label": "C. Difficile", + "value": "CRITICAL RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Toxin Blocker", + "value": "NEC FASC", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly tissue-penetrating lincosamide. Exceptional against Gram-positive aerobes (Staph/Strep) and deep anaerobes. The absolute worst offender for causing C. difficile colitis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1.8 g/day** (e.g., 600 mg TDS) for adults.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Used in Necrotising Fasciitis and Toxic Shock Syndrome because it halts the bacterial ribosomes from synthesizing deadly flesh-eating exotoxins.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Clindamycin is a lincosamide with excellent bone and soft tissue penetration for staphylococcal and anaerobic infections, but carries the highest risk of C. difficile-associated diarrhoea among antibiotics.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Clostridioides difficile-associated diarrhea (CDAD) and pseudomembranous colitis. Can be fatal, especially in the elderly. HIGH — Standard antibiotic diarrhea, esophageal ulceration (if swallowed without water).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Dermatological", + "val": "MODERATE — Maculopapular rash, rare SJS.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Cardiac arrest if IV push is too rapid. Must infuse over 10-30 mins.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Skin/Soft Tissue Infection", + "val": "**PO** 300-450 mg **QID**.", + "tags": [] + }, + { + "key": "Necrotising Fasciitis (Adjunct)", + "val": "**IV** 600 mg **TDS** (Alongside high-dose Penicillin and surgical debridement).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "SAFE — Hepatically metabolised. No dose adjustment required in CKD.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dalacin C", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (150 mg). Oral liquid.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (600 mg/4 mL) for **IV** / **IM**.", + "tags": [] + }, + { + "key": "Topical", + "val": "Vaginal cream, topical acne lotion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Staph/Strep infections in penicillin-allergic patients, anaerobic infections (above the diaphragm), Necrotising Fasciitis, osteomyelitis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Niche role for toxin-mediated diseases or severe penicillin allergy. Outstanding bone and joint penetration.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of C. difficile colitis or inflammatory bowel disease.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Clindamycin pregnancy row is Category A/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Neuromuscular blocking agents (Anaesthetics). Clindamycin has intrinsic neuromuscular blocking properties and will dangerously prolong the paralysis of surgical muscle relaxants.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn the patient: 'If you develop severe, watery, or bloody diarrhea, stop taking the capsules immediately and contact us.' Do NOT prescribe anti-diarrheals (Loperamide) as this traps the C. diff toxin in the gut, causing megacolon.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Exotoxin Weapon", + "val": "In severe Necrotising Fasciitis ('flesh-eating disease'), Penicillin alone fails because it only works on actively dividing bacteria (the 'Eagle effect'), and the tissue is already dying from pre-formed toxins. Clindamycin ignores this and shuts down the toxin factories instantly.", + "tags": [] + }, + { + "key": "The Anaerobic Divide", + "val": "Clindamycin is fantastic for anaerobes *above* the diaphragm (mouth/lung abscesses). Metronidazole is the drug of choice for anaerobes *below* the diaphragm (gut/pelvis) due to high Bacteroides resistance to Clindamycin.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to the 50S ribosomal subunit. Halts bacterial protein synthesis. Because bacterial exotoxins (like Panton-Valentine leukocidin in MRSA or Pyrogenic exotoxin in Strep) are proteins, Clindamycin instantly stops their production, halting tissue necrosis.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** Rapid absorption.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours. Excellent bioavailability (90%).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DALACIN C ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Lincosamide — Highly tissue-penetrating lincosamide." + }, + { + "label": "Route / Formulation", + "value": "Capsules (150 mg). Oral liquid. (Dalacin C)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 300-450 mg **QID**. Max **1.8 g/day** (e.g., 600 mg TDS) for adults." + }, + { + "label": "Key Indication Doses", + "value": "Severe Skin/Soft Tissue Infection: **PO** 300-450 mg **QID**. Necrotising Fasciitis (Adjunct): **IV** 600 mg **TDS** (Alongside high-dose Penicillin and surgical debridement). Renal Impairment: Hepatically metabolised. No dose adjustment required in CKD." + }, + { + "label": "Best Uses", + "value": "Clindamycin is a lincosamide with excellent bone and soft tissue penetration for staphylococcal and anaerobic infections, but carries the highest risk of C. difficile-associated diarrhoea among antibiotics." + }, + { + "label": "Avoid / Cautions", + "value": "History of C. difficile colitis or inflammatory bowel disease. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Clostridioides difficile-associated diarrhea (CDAD) and pseudomembranous colitis. Can be fatal, especially in the elderly. HIGH — Standard antibiotic diarrhea, esophageal ulceration (if swallowed without water). Dermatological: Maculopapular rash, rare SJS. Cardiovascular: Cardiac arrest if IV push is too rapid. Must infuse over 10-30 mins." + }, + { + "label": "Key Interactions", + "value": "Neuromuscular blocking agents (Anaesthetics). Clindamycin has intrinsic neuromuscular blocking properties and will dangerously prolong the paralysis of surgical muscle relaxants." + }, + { + "label": "Monitoring", + "value": "Warn the patient: 'If you develop severe, watery, or bloody diarrhea, stop taking the capsules immediately and contact us.' Do NOT prescribe anti-diarrheals (Loperamide) as this traps the C. diff toxin in the gut, causing megacolon." + }, + { + "label": "Clinical Pearl", + "value": "In severe Necrotising Fasciitis ('flesh-eating disease'), Penicillin alone fails because it only works on actively dividing bacteria (the 'Eagle effect'), and the tissue is already dying from pre-formed toxins. Clindamycin ignores this and shuts down the toxin factories instantly." + } + ] + }, + { + "slug": "co-trimoxazole", + "name": "Co-trimoxazole", + "class": "Antibiotic", + "subclass": "Sulfonamide + Trimethoprim", + "category": "Infectious Diseases - Other Antibiotics", + "accent": "#ea580c", + "tag": "SULFONAMIDE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Weight Based", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10 h", + "cls": "", + "flag": "" + }, + { + "label": "Hyperkalemia", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "SJS/TEN", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Synergistic combination of Sulfamethoxazole and Trimethoprim (Bactrim). Devastating to MRSA and Pneumocystis (PCP), but highly toxic to the kidneys and skin.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Variable. Standard max is 4 Double Strength (DS) tablets/day, but PCP doses are massive.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Acts identically to a potassium-sparing diuretic (Amiloride). Will cause lethal hyperkalemia if given to elderly patients on ACEi/ARBs.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Co-trimoxazole is the first-line treatment and prophylaxis for Pneumocystis jirovecii (PJP) and selected UTIs, but causes severe hyperkalaemia, bone marrow suppression, and life-threatening skin reactions (SJS/TEN).", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal & Electrolytes", + "val": "CRITICAL — Severe hyperkalemia (blocks K+ excretion), AKI, crystalluria.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "CRITICAL — Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN).", + "tags": [] + }, + { + "key": "Haematological", + "val": "HIGH — Bone marrow suppression (leukopenia, thrombocytopenia, megaloblastic anemia due to folate antagonism).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "UTI / MRSA Skin Infection", + "val": "**PO** 1 DS tablet (800/160 mg) **BD**.", + "tags": [] + }, + { + "key": "PCP Prophylaxis", + "val": "**PO** 1 DS tablet 3 times per week.", + "tags": [] + }, + { + "key": "PCP Treatment (Severe)", + "val": "**IV** 120 mg/kg/day (of combined product) in 4 divided doses (Massive volume, ICU monitoring).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Halve dose if **eGFR** 15-30. Avoid entirely if **eGFR** < 15.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Bactrim, Resprim. Available as Single Strength (400/80) or Double Strength (DS) (800/160).", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets, Oral Liquid.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** infusion (Requires massive dilution volumes).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for specific indications.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "MRSA skin infections, Pneumocystis jirovecii (PCP), Toxoplasmosis, complicated UTI.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line oral option for severe community MRSA. Anchor drug in HIV/immunocompromised patients for PCP.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Sulfonamide allergy, severe hepatic impairment, severe renal impairment when monitoring cannot be performed, and folate-deficiency states.", + "tags": [], + "patient": { + "factors": ["hepatic", "renal", "allergy-sulfa"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Co-trimoxazole requires avoidance/review with sulfonamide allergy and severe hepatic or renal impairment." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category C. Avoid in 1st trimester (blocks folate, causing neural tube defects) and near term (kernicterus).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — ACEi, ARBs, Spironolactone (Guarantees severe hyperkalemia).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Methotrexate (Both block folate synthesis. Combo causes fatal bone marrow failure).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Warfarin (Drastically increases INR).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Strict **U&E** monitoring within 3 days of starting in the elderly (potassium spike). Monitor **FBC**.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "Cease immediately and admit to ED if ANY mucosal blistering, rash, or unexplained fever occurs.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Creatinine Fake-out", + "val": "Trimethoprim competitively blocks the tubular secretion of creatinine in the kidney. Within days of starting, the patient's blood creatinine will rise by 10-30%. If the Urea is stable, this is a harmless lab artefact, NOT a true AKI.", + "tags": [] + }, + { + "key": "The Fluid Requirement", + "val": "Sulfa drugs can crystalize in the renal tubules. Ensure the patient is heavily hydrated to flush the drug out.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Sequential dual blockade of bacterial folate synthesis. Sulfa blocks Dihydropteroate synthase; Trimethoprim blocks Dihydrofolate reductase. Highly bactericidal together.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-4 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10 hours. Heavily renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - BACTRIM/SEPTRIN ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Sulfonamide + Trimethoprim — Synergistic combination of Sulfamethoxazole and Trimethoprim (Bactrim)." + }, + { + "label": "Route / Formulation", + "value": "Tablets, Oral Liquid. (Bactrim, Resprim. Available as Single Strength (400/80) or Double Strength (DS) (800/160).)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1 DS tablet (800/160 mg) **BD**. Variable. Standard max is 4 Double Strength (DS) tablets/day, but PCP doses are massive." + }, + { + "label": "Key Indication Doses", + "value": "UTI / MRSA Skin Infection: **PO** 1 DS tablet (800/160 mg) **BD**. PCP Prophylaxis: **PO** 1 DS tablet 3 times per week. PCP Treatment (Severe): **IV** 120 mg/kg/day (of combined product) in 4 divided doses (Massive volume, ICU monitoring). Renal Impairment: Halve dose if **eGFR** 15-30. Avoid entirely if **eGFR** < 15." + }, + { + "label": "Best Uses", + "value": "Co-trimoxazole is the first-line treatment and prophylaxis for Pneumocystis jirovecii (PJP) and selected UTIs, but causes severe hyperkalaemia, bone marrow suppression, and life-threatening skin reactions (SJS/TEN)." + }, + { + "label": "Avoid / Cautions", + "value": "Sulfa allergy, severe hepatic/renal failure, folate deficiency. **Pregnancy** Category C. Avoid in 1st trimester (blocks folate, causing neural tube defects) and near term (kernicterus)." + }, + { + "label": "Key Risks", + "value": "Renal & Electrolytes: Severe hyperkalemia (blocks K+ excretion), AKI, crystalluria. Dermatological: Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN). Haematological: Bone marrow suppression (leukopenia, thrombocytopenia, megaloblastic anemia due to folate antagonism)." + }, + { + "label": "Key Interactions", + "value": "ACEi, ARBs, Spironolactone (Guarantees severe hyperkalemia). Methotrexate (Both block folate synthesis. Combo causes fatal bone marrow failure). Warfarin (Drastically increases INR)." + }, + { + "label": "Monitoring", + "value": "Strict **U&E** monitoring within 3 days of starting in the elderly (potassium spike). Monitor **FBC**. Cease immediately and admit to ED if ANY mucosal blistering, rash, or unexplained fever occurs." + }, + { + "label": "Clinical Pearl", + "value": "Trimethoprim competitively blocks the tubular secretion of creatinine in the kidney. Within days of starting, the patient's blood creatinine will rise by 10-30%. If the Urea is stable, this is a harmless lab artefact, NOT a true AKI." + } + ] + }, + { + "slug": "colistin", + "name": "Colistin", + "class": "Antibiotic", + "subclass": "Polymyxin", + "category": "Infectious Diseases - Other Antibiotics", + "accent": "#ea580c", + "tag": "POLYMYXIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Calculated in IU", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "14 h", + "cls": "", + "flag": "" + }, + { + "label": "Nephrotoxicity", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Neurotoxicity", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Polymyxin E. An ancient, highly toxic antibiotic resurrected as the absolute last line of defense against Multi-Drug Resistant (MDR) Gram-negative superbugs (e.g., Carbapenem-Resistant Enterobacteriaceae).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Calculated strictly in Millions of International Units (IU) based on renal function.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Devastates the kidneys and nervous system. Acts literally like a biological detergent, tearing apart the bacterial cell membrane.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Colistin is a last-resort polymyxin for extensively drug-resistant gram-negative infections, but causes significant nephrotoxicity and neurotoxicity and is reserved for when no alternatives exist.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal", + "val": "CRITICAL — Acute Tubular Necrosis, severe AKI (occurs in up to 50% of patients treated systemically).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Perioral paresthesia, dizziness, confusion, ataxia. CRITICAL — Neuromuscular blockade leading to respiratory paralysis/apnoea.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Severe bronchospasm (if given via nebuliser without prior bronchodilator).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "MDR Sepsis (Loading)", + "val": "**IV** 9 Million IU STAT over 1-2 hours (Specialist critical care only).", + "tags": [] + }, + { + "key": "Maintenance", + "val": "**IV** 4.5 Million IU **BD** (12-hourly).", + "tags": [] + }, + { + "key": "Inhaled (CF / Vent-Associated Pneumonia)", + "val": "**Inhaled** 1-2 Million IU via nebuliser **BD** or **TDS**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Massive dose reductions required if **eGFR** < 50. Handled by highly specialized nomograms.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Colymycin", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (Colistimethate sodium, CMS) for **IV** infusion. CMS is an inactive prodrug that slowly converts to active colistin in the blood.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital ICU/ID supply only. Strictly restricted.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Life-threatening infections caused by MDR Gram-negatives (Pseudomonas, Acinetobacter, Klebsiella) resistant to all other antibiotics.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "The absolute last resort. Used only when the lab reports 'Resistant to Everything Except Colistin'.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Myasthenia Gravis (guaranteed respiratory paralysis).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3. (Used if maternal life is at immediate risk from MDR sepsis).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Colistin pregnancy row is Category B3/life-threatening infection caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Neuromuscular blocking agents (Rocuronium) and Aminoglycosides. The combination causes prolonged, fatal respiratory muscle paralysis.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Nephrotoxins (NSAIDs, Vancomycin). Synergistic kidney destruction.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Strict daily **U&E** and **eGFR** monitoring. Renal function often deteriorates rapidly during the course.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Monitor **RR** and neuromuscular strength. If nebulising, give Salbutamol 15 mins prior to prevent severe airway spasm.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Prodrug Lag", + "val": "Because it is administered as the inactive prodrug CMS, it takes hours for active colistin levels to rise in the blood. In fulminant septic shock, this delay is lethal, which is why a massive 9 Million IU Loading Dose is mandatory to try and saturate the blood quickly.", + "tags": [] + }, + { + "key": "The Lung Barrier", + "val": "IV Colistin penetrates the lung tissue terribly. If treating a multi-drug resistant pneumonia, IV Colistin will fail. You MUST give it both IV *and* nebulised directly into the lungs to achieve high enough concentrations.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Acts as a cationic detergent. Binds to lipopolysaccharides (LPS) and phospholipids in the outer cell membrane of Gram-negative bacteria, displacing calcium and magnesium, causing the membrane to rupture and cell contents to leak out.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Hours (Delayed because CMS prodrug must slowly convert to active colistin).", + "tags": [] + }, + { + "key": "Half-life", + "val": "14 hours. Predominantly renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - COLISTIN LINK ARTG/PI and PBS check checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Polymyxin — Polymyxin E." + }, + { + "label": "Route / Formulation", + "value": "Vials (Colistimethate sodium, CMS) for **IV** infusion. CMS is an inactive prodrug that slowly converts to active colistin in the blood. (Colymycin)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 9 Million IU STAT over 1-2 hours (Specialist critical care only). Calculated strictly in Millions of International Units (IU) based on renal function." + }, + { + "label": "Key Indication Doses", + "value": "MDR Sepsis (Loading): **IV** 9 Million IU STAT over 1-2 hours (Specialist critical care only). Maintenance: **IV** 4.5 Million IU **BD** (12-hourly). Inhaled (CF / Vent-Associated Pneumonia): **Inhaled** 1-2 Million IU via nebuliser **BD** or **TDS**. Renal Impairment: Massive dose reductions required if **eGFR** < 50. Handled by highly specialized nomograms." + }, + { + "label": "Best Uses", + "value": "Colistin is a last-resort polymyxin for extensively drug-resistant gram-negative infections, but causes significant nephrotoxicity and neurotoxicity and is reserved for when no alternatives exist." + }, + { + "label": "Avoid / Cautions", + "value": "Myasthenia Gravis (guaranteed respiratory paralysis). **Pregnancy** Category B3. (Used if maternal life is at immediate risk from MDR sepsis)." + }, + { + "label": "Key Risks", + "value": "Renal: Acute Tubular Necrosis, severe AKI (occurs in up to 50% of patients treated systemically). Neurological: Perioral paresthesia, dizziness, confusion, ataxia. CRITICAL — Neuromuscular blockade leading to respiratory paralysis/apnoea. Respiratory: Severe bronchospasm (if given via nebuliser without prior bronchodilator)." + }, + { + "label": "Key Interactions", + "value": "Neuromuscular blocking agents (Rocuronium) and Aminoglycosides. The combination causes prolonged, fatal respiratory muscle paralysis. Nephrotoxins (NSAIDs, Vancomycin). Synergistic kidney destruction." + }, + { + "label": "Monitoring", + "value": "Strict daily **U&E** and **eGFR** monitoring. Renal function often deteriorates rapidly during the course. Monitor **RR** and neuromuscular strength. If nebulising, give Salbutamol 15 mins prior to prevent severe airway spasm." + }, + { + "label": "Clinical Pearl", + "value": "Because it is administered as the inactive prodrug CMS, it takes hours for active colistin levels to rise in the blood. In fulminant septic shock, this delay is lethal, which is why a massive 9 Million IU Loading Dose is mandatory to try and saturate the blood quickly." + } + ] + }, + { + "slug": "ertapenem", + "name": "Ertapenem", + "class": "Antibiotic", + "subclass": "Carbapenem", + "category": "Infectious Diseases - Other Antibiotics", + "accent": "#ea580c", + "tag": "CARBAPENEM", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4 h", + "cls": "", + "flag": "" + }, + { + "label": "Freq", + "value": "ONCE DAILY", + "cls": "good", + "flag": "" + }, + { + "label": "Pseudomonas", + "value": "NO COVER", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly convenient, once-daily IV carbapenem. Outstanding cover against ESBL-producing Gram-negative gut bugs and anaerobes. Crucially, it lacks coverage against Pseudomonas or Enterococcus.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1 g/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The only carbapenem that does NOT cover Pseudomonas. Do not use for hospital-acquired pneumonia or severe neutropenic fever.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ertapenem is a once-daily carbapenem suitable for community-acquired complicated infections and outpatient IV therapy, but lacks Pseudomonas coverage unlike meropenem.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "MODERATE — Seizures, encephalopathy (Risk is highest in unadjusted severe renal failure or pre-existing CNS lesions).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Diarrhea, C. difficile infection.", + "tags": [] + }, + { + "key": "Immunological", + "val": "LOW — Beta-lactam hypersensitivity cross-reactivity.", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "ESBL UTI / Intra-abdominal Sepsis", + "val": "**IV** / **IM** 1 g **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Halve the dose. If **eGFR** < 30, give 500 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Invanz", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (1 g powder) for **IV** infusion or deep **IM** injection (mixed with 1% lidocaine).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply. Restricted by Antimicrobial Stewardship.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Complicated intra-abdominal infections, complicated UTI/pyelonephritis caused by ESBL-producing organisms, diabetic foot infections.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "The absolute gold-standard 'OPAT' (Outpatient Parenteral Antimicrobial Therapy) drug. Its once-daily dosing allows patients with severe ESBL UTIs to be discharged home and treated by a visiting nurse.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Anaphylaxis to carbapenems/penicillins. Known Pseudomonas infection.", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Ertapenem pregnancy row is Category B3/benefit-risk caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Sodium Valproate. Ertapenem rapidly destroys valproate blood levels, dropping them to sub-therapeutic levels within 24 hours, guaranteeing breakthrough seizures in epileptics. AVOID.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **eGFR** to ensure the 1g dose is safe. Track **FBC** if on prolonged OPAT courses.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Observe for neurological changes, myoclonus or seizures, especially in older adults or renal impairment.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Older adults need monitoring for carbapenem neurotoxicity during ertapenem treatment." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The OPAT Champion", + "val": "If a patient is clinically stable but their urine grows an E. coli resistant to Ceftriaxone and Tazocin (an ESBL), they usually require IV Meropenem TDS, keeping them stuck in hospital. Ertapenem 1g OD allows them to go home immediately.", + "tags": [] + }, + { + "key": "The A-P-E Mnemonic", + "val": "Ertapenem is the 'A-P-E' exception among carbapenems: It does NOT cover Acinetobacter, Pseudomonas, or Enterococcus.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds PBPs, shattering the bacterial cell wall. Extremely resistant to destruction by beta-lactamases (including ESBLs).", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "4 hours (Highly protein bound to albumin, which keeps it in the blood far longer than Meropenem, allowing OD dosing).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - INVANZ ertapenem ARTG/PI and PBS check checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Carbapenem — Highly convenient, once-daily IV carbapenem." + }, + { + "label": "Route / Formulation", + "value": "Vials (1 g powder) for **IV** infusion or deep **IM** injection (mixed with 1% lidocaine). (Invanz)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** / **IM** 1 g **OD**. Max **1 g/day**." + }, + { + "label": "Key Indication Doses", + "value": "ESBL UTI / Intra-abdominal Sepsis: **IV** / **IM** 1 g **OD**. Renal Impairment: Halve the dose. If **eGFR** < 30, give 500 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Ertapenem is a once-daily carbapenem suitable for community-acquired complicated infections and outpatient IV therapy, but lacks Pseudomonas coverage unlike meropenem." + }, + { + "label": "Avoid / Cautions", + "value": "Anaphylaxis to carbapenems/penicillins. Known Pseudomonas infection. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Neurological: Seizures, encephalopathy (Risk is highest in unadjusted severe renal failure or pre-existing CNS lesions). Gastrointestinal: Diarrhea, C. difficile infection. Immunological: Beta-lactam hypersensitivity cross-reactivity." + }, + { + "label": "Key Interactions", + "value": "Sodium Valproate. Ertapenem rapidly destroys valproate blood levels, dropping them to sub-therapeutic levels within 24 hours, guaranteeing breakthrough seizures in epileptics. AVOID." + }, + { + "label": "Monitoring", + "value": "Check **eGFR** to ensure the 1g dose is safe. Track **FBC** if on prolonged OPAT courses. Observe for neurological changes/myoclonus in the elderly." + }, + { + "label": "Clinical Pearl", + "value": "If a patient is clinically stable but their urine grows an E. coli resistant to Ceftriaxone and Tazocin (an ESBL), they usually require IV Meropenem TDS, keeping them stuck in hospital. Ertapenem 1g OD allows them to go home immediately." + } + ] + }, + { + "slug": "meropenem", + "name": "Meropenem", + "class": "Antibiotic", + "subclass": "Carbapenem", + "category": "Infectious Diseases - Other Antibiotics", + "accent": "#ea580c", + "tag": "CARBAPENEM", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "6 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1 h", + "cls": "", + "flag": "" + }, + { + "label": "Valproate", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Seizure", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-broad-spectrum carbapenem antibiotic. Resistant to almost all beta-lactamases including ESBLs. Highly restricted reserve agent.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **6 g/day** (For severe meningitis).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Destroys Sodium Valproate blood levels. Co-administration guarantees breakthrough seizures in epileptic patients.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Meropenem is the broadest-spectrum carbapenem reserved for multi-resistant and life-threatening infections, but must be used as last resort to prevent carbapenem resistance and lowers the seizure threshold.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "MODERATE — Can lower seizure threshold (though significantly safer than Imipenem).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — C. difficile infection, nausea, diarrhea.", + "tags": [] + }, + { + "key": "Immunological", + "val": "LOW — Cross-reactivity with true IgE penicillin allergy is very low (~1%), but caution is required.", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Sepsis / ESBL", + "val": "**IV** 1 g q8h.", + "tags": [] + }, + { + "key": "Bacterial Meningitis", + "val": "**IV** 2 g q8h (To ensure adequate BBB penetration).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** 10-25, give 1g q12h. If **eGFR** < 10, give 500mg q24h.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Merrem", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (500 mg, 1 g) for **IV** injection/infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply. Strictly governed by Antimicrobial Stewardship.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "ESBL-producing intra-abdominal/urinary sepsis, severe hospital-acquired pneumonia, bacterial meningitis.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Last line of defense against highly resistant Gram-negative organisms. Do not use for simple CAP or cellulitis.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Anaphylaxis to carbapenems.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B2.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Meropenem pregnancy row is Category B2/source-reviewed benefit-risk context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Sodium Valproate (Epilim). Meropenem rapidly accelerates the hepatic breakdown of Valproate. Blood levels drop to zero within 24 hours. The interaction cannot be overcome by increasing Valproate dose. Use alternative antibiotic or antiepileptic.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Monitor **U&E** and **eGFR** to guide dose reduction. Monitor **LFTs**.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor for neurological signs/seizures in patients with severe renal failure (accumulation risk).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Extended Infusions", + "val": "Like Piperacillin/Tazobactam, running Meropenem over 3-4 hours instead of a 30-minute bolus massively increases the 'Time above MIC', providing significantly better clinical cure rates in critical ICU patients.", + "tags": [] + }, + { + "key": "The ESBL Rule", + "val": "If a urine or blood culture flags an 'ESBL' (Extended-Spectrum Beta-Lactamase) organism, Ceftriaxone and Tazocin will fail. You MUST step up to a carbapenem like Meropenem or Ertapenem.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to multiple Penicillin-Binding Proteins (PBPs) causing rapid bacterial cell death. Exceptionally stable against hydrolysis by beta-lactamases.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1 hour. Renally cleared.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - MEROPENEM-AFT ARTG/PI and PBS check checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Carbapenem — Ultra-broad-spectrum carbapenem antibiotic." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (500 mg, 1 g) for **IV** injection/infusion. (Merrem)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 1 g q8h. Max **6 g/day** (For severe meningitis)." + }, + { + "label": "Key Indication Doses", + "value": "Severe Sepsis / ESBL: **IV** 1 g q8h. Bacterial Meningitis: **IV** 2 g q8h (To ensure adequate BBB penetration). Renal Impairment: If **eGFR** 10-25, give 1g q12h. If **eGFR** < 10, give 500mg q24h." + }, + { + "label": "Best Uses", + "value": "Meropenem is the broadest-spectrum carbapenem reserved for multi-resistant and life-threatening infections, but must be used as last resort to prevent carbapenem resistance and lowers the seizure threshold." + }, + { + "label": "Avoid / Cautions", + "value": "Anaphylaxis to carbapenems. **Pregnancy** Category B2." + }, + { + "label": "Key Risks", + "value": "Neurological: Can lower seizure threshold (though significantly safer than Imipenem). Gastrointestinal: C. difficile infection, nausea, diarrhea. Immunological: Cross-reactivity with true IgE penicillin allergy is very low (~1%), but caution is required." + }, + { + "label": "Key Interactions", + "value": "Sodium Valproate (Epilim). Meropenem rapidly accelerates the hepatic breakdown of Valproate. Blood levels drop to zero within 24 hours. The interaction cannot be overcome by increasing Valproate dose. Use alternative antibiotic or antiepileptic." + }, + { + "label": "Monitoring", + "value": "Monitor **U&E** and **eGFR** to guide dose reduction. Monitor **LFTs**. Monitor for neurological signs/seizures in patients with severe renal failure (accumulation risk)." + }, + { + "label": "Clinical Pearl", + "value": "Like Piperacillin/Tazobactam, running Meropenem over 3-4 hours instead of a 30-minute bolus massively increases the 'Time above MIC', providing significantly better clinical cure rates in critical ICU patients." + } + ] + }, + { + "slug": "metronidazole", + "name": "Metronidazole", + "class": "Antibiotic", + "subclass": "Nitroimidazole", + "category": "Infectious Diseases - Other Antibiotics", + "accent": "#ea580c", + "tag": "NITROIMIDAZOLE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "2 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "8 h", + "cls": "", + "flag": "" + }, + { + "label": "Disulfiram", + "value": "ALCOHOL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Neuropathy", + "value": "CHRONIC", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent bactericidal agent against strict anaerobes and protozoa. Penetrates abscesses, bone, and the blood-brain barrier beautifully.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2 g/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Interacts violently with alcohol. Prolonged courses cause peripheral neuropathy.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Metronidazole is the first-line treatment for anaerobic infections and C. difficile, but causes a severe disulfiram-like reaction with alcohol and peripheral neuropathy with prolonged use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Peripheral neuropathy (usually with courses > 14 days), optic neuropathy. CRITICAL — Seizures, encephalopathy at massive doses.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe nausea, metallic taste in mouth, anorexia.", + "tags": [] + }, + { + "key": "Haematological", + "val": "LOW — Mild, reversible neutropenia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Anaerobic Sepsis / Abscess", + "val": "**IV** 500 mg q12h (or **PO** 400 mg q12h).", + "tags": [] + }, + { + "key": "C. Difficile (Mild)", + "val": "**PO** 400 mg **TDS** for 10-14 days.", + "tags": [] + }, + { + "key": "Trichomoniasis / Giardia", + "val": "**PO** 2 g STAT single dose.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "MANDATORY — Reduce dose in severe liver disease (metabolised hepatically).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Flagyl, Metrogyl", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (200 mg, 400 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-mixed infusion bags (500 mg/100 mL) for **IV** use. Suppositories for **PR**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Intra-abdominal sepsis, pelvic inflammatory disease, brain abscess, C. difficile, Trichomonas, Giardia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The foundational drug for any infection 'below the diaphragm' to cover gut anaerobes (Bacteroides).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active CNS disease (seizures).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2. Often avoided in 1st trimester but used if required.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Metronidazole pregnancy row is Category B2/benefit-risk caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Alcohol. Causes a severe 'Disulfiram-like' reaction (accumulation of acetaldehyde) resulting in violent vomiting, flushing, tachycardia, and hypotension. Must avoid alcohol during and for 48h after course.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Warfarin. Metronidazole inhibits CYP2C9, drastically spiking INR. Halve the Warfarin dose proactively.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Warn patients about metallic taste and strict zero-alcohol rule.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor **LFTs** if prolonged course.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Bioavailability Win", + "val": "Oral metronidazole has 100% bioavailability. If the patient can swallow, switch from IV to PO instantly to save money and protect their veins.", + "tags": [] + }, + { + "key": "The Neuropathy Trap", + "val": "If an intra-abdominal abscess requires 6 weeks of metronidazole, actively ask the patient every week about tingling in their fingers or toes. Cease the drug if neuropathy starts, as it can become permanent.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug activated strictly by anaerobic bacteria. Forms toxic free radicals that catastrophically shatter bacterial DNA.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "8 hours. Exceptional bioavailability (near 100%).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - FLAGYL/metronidazole ARTG/CMI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Nitroimidazole — Highly potent bactericidal agent against strict anaerobes and protozoa." + }, + { + "label": "Route / Formulation", + "value": "Tablets (200 mg, 400 mg). (Flagyl, Metrogyl)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 500 mg q12h (or **PO** 400 mg q12h). Max **2 g/day**." + }, + { + "label": "Key Indication Doses", + "value": "Anaerobic Sepsis / Abscess: **IV** 500 mg q12h (or **PO** 400 mg q12h). C. Difficile (Mild): **PO** 400 mg **TDS** for 10-14 days. Trichomoniasis / Giardia: **PO** 2 g STAT single dose. Hepatic Impairment: Reduce dose in severe liver disease (metabolised hepatically)." + }, + { + "label": "Best Uses", + "value": "Metronidazole is the first-line treatment for anaerobic infections and C. difficile, but causes a severe disulfiram-like reaction with alcohol and peripheral neuropathy with prolonged use." + }, + { + "label": "Avoid / Cautions", + "value": "Active CNS disease (seizures). **Pregnancy** Category B2. Often avoided in 1st trimester but used if required." + }, + { + "label": "Key Risks", + "value": "Neurological: Peripheral neuropathy (usually with courses > 14 days), optic neuropathy. CRITICAL — Seizures, encephalopathy at massive doses. Gastrointestinal: Severe nausea, metallic taste in mouth, anorexia. Haematological: Mild, reversible neutropenia." + }, + { + "label": "Key Interactions", + "value": "Alcohol. Causes a severe 'Disulfiram-like' reaction (accumulation of acetaldehyde) resulting in violent vomiting, flushing, tachycardia, and hypotension. Must avoid alcohol during and for 48h after course. Warfarin. Metronidazole inhibits CYP2C9, drastically spiking INR. Halve the Warfarin dose proactively." + }, + { + "label": "Monitoring", + "value": "Warn patients about metallic taste and strict zero-alcohol rule. Monitor **LFTs** if prolonged course." + }, + { + "label": "Clinical Pearl", + "value": "Oral metronidazole has 100% bioavailability. If the patient can swallow, switch from IV to PO instantly to save money and protect their veins." + } + ] + }, + { + "slug": "moxifloxacin", + "name": "Moxifloxacin", + "class": "Antibiotic", + "subclass": "Fluoroquinolone", + "category": "Infectious Diseases - Other Antibiotics", + "accent": "#ea580c", + "tag": "FLUOROQUINOLONE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12 h", + "cls": "", + "flag": "" + }, + { + "label": "Tendon Rupture", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "UTI Treatment", + "value": "USELESS", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The 'Respiratory Fluoroquinolone'. Uniquely potent against Streptococcus pneumoniae and deep anaerobes. Completely bypasses the kidneys, making it useless for UTIs but incredibly safe in renal failure.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Black Box warnings for Achilles tendon rupture and aortic dissection. Do not use for mild infections.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Moxifloxacin is a respiratory fluoroquinolone covering atypicals and anaerobes without renal dose adjustment, but has the highest QTc prolongation risk of all fluoroquinolones and carries tendon rupture risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Musculoskeletal", + "val": "CRITICAL — Achilles tendon rupture (can occur suddenly and bilaterally).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CRITICAL — Aortic aneurysm dissection/rupture. HIGH — **QTc** prolongation (highest risk of all fluoroquinolones).", + "tags": [], + "patient": { + "factors": ["qtc", "allergy-fluoro"], + "action": "caution", + "severity": "danger", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "HIGH — Peripheral neuropathy, seizures, insomnia/psychosis.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe CAP / Intra-abdominal Sepsis", + "val": "**PO** or **IV** 400 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "SAFE — No dose adjustment required in severe CKD or dialysis (100% hepatic/biliary clearance).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Avelox", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (400 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-mixed infusion bags for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe Community Acquired Pneumonia (CAP), complicated intra-abdominal infections, pelvic inflammatory disease.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "A powerful monotherapy option for severe pneumonia in penicillin-allergic patients, as it covers typicals, atypicals, and anaerobes in a single pill.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Baseline **QTc** > 500 ms, history of quinolone-associated tendon disorder, or major aortic aneurysm/dissection risk without specialist justification.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 500 + } + }, + "note": "Moxifloxacin requires avoidance/review with marked QTc prolongation or major QT-prolonging combinations." + } + }, + { + "key": "Pregnancy / Paeds", + "val": "CAUTION — **Pregnancy** Category B3; avoid routine use in pregnancy or children/adolescents unless benefits outweigh risks and no safer option is suitable.", + "tags": [], + "patient": { + "factors": ["pregnancy", "paediatric"], + "action": "caution", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Moxifloxacin pregnancy/paediatric row is a source-backed benefit-risk caution rather than an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Iron, Calcium, Antacids. Multi-valent cations bind the drug in the gut, dropping absorption to zero. Separate by 4 hours.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Amiodarone, Sotalol, SSRIs (Synergistic fatal QTc prolongation).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn patient to stop the drug instantly if they feel heel pain or sudden tearing chest/back pain.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Baseline **ECG** is recommended in older adults, QT-risk patients, electrolyte disturbance, or when combining with other QT-prolonging medicines.", + "tags": [], + "patient": { + "factors": ["elderly", "qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Monitor ECG/QTc risk when prescribing moxifloxacin to older adults or QT-risk patients." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The UTI Trap", + "val": "Because Moxifloxacin is metabolised entirely by the liver, NO active drug reaches the urine. If you prescribe Moxifloxacin for a urinary tract infection, the patient will die of urosepsis while taking a potent antibiotic. You MUST use Ciprofloxacin or Norfloxacin for UTIs.", + "tags": [] + }, + { + "key": "The Steroid Danger", + "val": "Co-prescribing oral Corticosteroids (Prednisolone) with Moxifloxacin exponentially multiplies the risk of an Achilles tendon rupture in the elderly.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits bacterial topoisomerase II (DNA gyrase) and topoisomerase IV, shattering bacterial DNA. Highly bactericidal.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours. Near 100% bioavailability.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12 hours. Metabolised purely by hepatic glucuronidation and sulfation.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - AVELOX moxifloxacin ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Fluoroquinolone — The 'Respiratory Fluoroquinolone'." + }, + { + "label": "Route / Formulation", + "value": "Tablets (400 mg). (Avelox)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** or **IV** 400 mg **OD**. Max **400 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Severe CAP / Intra-abdominal Sepsis: **PO** or **IV** 400 mg **OD**. Renal Impairment: No dose adjustment required in severe CKD or dialysis (100% hepatic/biliary clearance)." + }, + { + "label": "Best Uses", + "value": "Moxifloxacin is a respiratory fluoroquinolone covering atypicals and anaerobes without renal dose adjustment, but has the highest QTc prolongation risk of all fluoroquinolones and carries tendon rupture risk." + }, + { + "label": "Avoid / Cautions", + "value": "Baseline **QTc** > 500 ms, history of tendon disorders, aortic aneurysm." + }, + { + "label": "Key Risks", + "value": "Musculoskeletal: Achilles tendon rupture (can occur suddenly and bilaterally). Cardiovascular: Aortic aneurysm dissection/rupture. HIGH — **QTc** prolongation (highest risk of all fluoroquinolones). Neurological: Peripheral neuropathy, seizures, insomnia/psychosis." + }, + { + "label": "Key Interactions", + "value": "Iron, Calcium, Antacids. Multi-valent cations bind the drug in the gut, dropping absorption to zero. Separate by 4 hours. Amiodarone, Sotalol, SSRIs (Synergistic fatal QTc prolongation)." + }, + { + "label": "Monitoring", + "value": "Warn patient to stop the drug instantly if they feel heel pain or sudden tearing chest/back pain. Baseline **ECG** is mandatory in the elderly." + }, + { + "label": "Clinical Pearl", + "value": "Because Moxifloxacin is metabolised entirely by the liver, NO active drug reaches the urine. If you prescribe Moxifloxacin for a urinary tract infection, the patient will die of urosepsis while taking a potent antibiotic. You MUST use Ciprofloxacin or Norfloxacin for UTIs." + } + ] + }, + { + "slug": "norfloxacin", + "name": "Norfloxacin", + "class": "Antibiotic", + "subclass": "Fluoroquinolone", + "category": "Infectious Diseases - Other Antibiotics", + "accent": "#ea580c", + "tag": "FLUOROQUINOLONE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "800 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4 h", + "cls": "", + "flag": "" + }, + { + "label": "Systemic Abs.", + "value": "POOR", + "cls": "warn", + "flag": "" + }, + { + "label": "SBP Prophylaxis", + "value": "GOLD STANDARD", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "A narrow-application fluoroquinolone. Has very poor systemic absorption, meaning it only reaches therapeutic concentrations in the gut lumen and the urine.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **800 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never use for systemic infections (like pneumonia or bacteremia) because it does not reach the blood in high enough levels to kill anything.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Norfloxacin is a urinary fluoroquinolone for uncomplicated UTIs and SBP prophylaxis, but is increasingly restricted due to resistance and carries the same fluoroquinolone class risks.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Musculoskeletal", + "val": "CRITICAL — Tendon rupture (Black box warning for all quinolones).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CRITICAL — Aortic dissection. MODERATE — QTc prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "HIGH — Neuropathy, lowered seizure threshold.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Uncomplicated UTI", + "val": "**PO** 400 mg **BD** for 3 days.", + "tags": [] + }, + { + "key": "SBP Prophylaxis (Cirrhosis)", + "val": "**PO** 400 mg **OD** (Maintains a sterile gut to prevent bacterial translocation).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce to 400 mg OD if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Noroxin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (400 mg). Must be taken on an empty stomach.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Uncomplicated UTI, prophylaxis of Spontaneous Bacterial Peritonitis (SBP) in cirrhotic patients.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Largely reserved for SBP prophylaxis in severe liver failure, or resistant UTIs where other oral agents fail.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of tendon disorders, aortic aneurysm.", + "tags": [] + }, + { + "key": "Pregnancy / Paeds", + "val": "ABSOLUTE — **Pregnancy** Category B3. Avoid in children.", + "tags": [], + "patient": { + "factors": ["pregnancy", "paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Iron, Calcium, Magnesium (Antacids). Binds the drug in the gut, completely blocking absorption. Separate by 2-4 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn patient to stop the drug instantly if they feel heel pain.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The SBP Shield", + "val": "In patients with end-stage liver cirrhosis, gut bacteria physically migrate across the bowel wall into the ascitic fluid, causing fatal Spontaneous Bacterial Peritonitis (SBP). Because Norfloxacin absorbs poorly, it stays in the gut lumen and massacres the bacteria there, acting as a permanent shield against SBP.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits bacterial DNA gyrase. Excellent activity against E. coli and gut flora.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-4 hours. Renally and biliary cleared. Oral bioavailability is only 30-40% (compared to 100% for Ciprofloxacin).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - APO-NORFLOXACIN ARTG/PI and PBS check checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Fluoroquinolone — A narrow-application fluoroquinolone." + }, + { + "label": "Route / Formulation", + "value": "Tablets (400 mg). Must be taken on an empty stomach. (Noroxin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 400 mg **BD** for 3 days. Max **800 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Uncomplicated UTI: **PO** 400 mg **BD** for 3 days. SBP Prophylaxis (Cirrhosis): **PO** 400 mg **OD** (Maintains a sterile gut to prevent bacterial translocation). Renal Impairment: Reduce to 400 mg OD if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Norfloxacin is a urinary fluoroquinolone for uncomplicated UTIs and SBP prophylaxis, but is increasingly restricted due to resistance and carries the same fluoroquinolone class risks." + }, + { + "label": "Avoid / Cautions", + "value": "History of tendon disorders, aortic aneurysm." + }, + { + "label": "Key Risks", + "value": "Musculoskeletal: Tendon rupture (Black box warning for all quinolones). Cardiovascular: Aortic dissection. MODERATE — QTc prolongation. Neurological: Neuropathy, lowered seizure threshold." + }, + { + "label": "Key Interactions", + "value": "Iron, Calcium, Magnesium (Antacids). Binds the drug in the gut, completely blocking absorption. Separate by 2-4 hours." + }, + { + "label": "Monitoring", + "value": "Warn patient to stop the drug instantly if they feel heel pain. Check **eGFR**." + }, + { + "label": "Clinical Pearl", + "value": "In patients with end-stage liver cirrhosis, gut bacteria physically migrate across the bowel wall into the ascitic fluid, causing fatal Spontaneous Bacterial Peritonitis (SBP). Because Norfloxacin absorbs poorly, it stays in the gut lumen and massacres the bacteria there, acting as a permanent shield against SBP." + } + ] + }, + { + "slug": "amoxicillin", + "name": "Amoxicillin", + "class": "Antibiotic", + "subclass": "Aminopenicillin", + "category": "Infectious Diseases - Penicillins", + "accent": "#ea580c", + "tag": "BETA-LACTAM", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "3 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1 h", + "cls": "", + "flag": "" + }, + { + "label": "Rash", + "value": "COMMON", + "cls": "warn", + "flag": "" + }, + { + "label": "Anaphylaxis", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Foundational, broad-spectrum aminopenicillin. Highly effective for susceptible respiratory, ENT, and dental pathogens. Excellent oral bioavailability.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **3 g/day** (standard) or **4 g/day** (in high-dose specialist regimens).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Differentiate a true IgE-mediated allergy (hives/anaphylaxis) from a benign childhood viral rash before withholding.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Amoxicillin is a first-line broad-spectrum penicillin for respiratory, urinary, and dental infections, but causes a characteristic maculopapular rash in EBV/glandular fever that is not true allergy.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Immunological", + "val": "CRITICAL — IgE-mediated anaphylaxis, angioedema. MODERATE — Non-allergic maculopapular rash.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Diarrhea, nausea. MODERATE — C. difficile infection.", + "tags": [] + }, + { + "key": "Renal", + "val": "LOW — Crystalluria at massive IV doses.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "CAP / Otitis Media", + "val": "**PO** 500 mg to 1 g **TDS**.", + "tags": [] + }, + { + "key": "H. Pylori Eradication", + "val": "**PO** 1 g **BD** (as part of triple therapy).", + "tags": [] + }, + { + "key": "Endocarditis Prophylaxis", + "val": "**PO** 2 g STAT 60 mins prior to dental procedure.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Amoxil, Cilamox", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (250 mg, 500 mg). Oral liquid (125 mg/5mL, 250 mg/5mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Community-acquired pneumonia, acute otitis media, sinusitis, dental infections.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line oral step-down for susceptible respiratory infections.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of Type 1 (IgE) penicillin hypersensitivity.", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce dose frequency if **eGFR** < 30.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Amoxicillin dose interval should be adjusted in severe renal impairment." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Amoxicillin pregnancy row is Category A/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Allopurinol (Concurrent use massively increases the risk of a severe skin rash).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Methotrexate (Penicillins reduce renal clearance of MTX, risking fatal bone marrow toxicity).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Observe for 30 mins after first dose for signs of anaphylaxis.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** to guide dosing frequency.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The EBV Rash", + "val": "Giving amoxicillin to a patient with infectious mononucleosis (glandular fever) guarantees a severe, full-body maculopapular rash in 90% of cases. This is NOT a true allergy, but it will be labeled as one forever.", + "tags": [] + }, + { + "key": "Food Independent", + "val": "Unlike flucloxacillin, amoxicillin absorption is excellent regardless of food intake.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Bactericidal. Binds to penicillin-binding proteins (PBPs) inside the bacterial cell wall, halting peptidoglycan synthesis and causing cell lysis.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-1.5 hours (Renally cleared).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - AMOXYCILLIN SANDOZ ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Aminopenicillin — Foundational, broad-spectrum aminopenicillin." + }, + { + "label": "Route / Formulation", + "value": "Capsules (250 mg, 500 mg). Oral liquid (125 mg/5mL, 250 mg/5mL). (Amoxil, Cilamox)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 500 mg to 1 g **TDS**. Max **3 g/day** (standard) or **4 g/day** (in high-dose specialist regimens)." + }, + { + "label": "Key Indication Doses", + "value": "CAP / Otitis Media: **PO** 500 mg to 1 g **TDS**. H. Pylori Eradication: **PO** 1 g **BD** (as part of triple therapy). Endocarditis Prophylaxis: **PO** 2 g STAT 60 mins prior to dental procedure." + }, + { + "label": "Best Uses", + "value": "Amoxicillin is a first-line broad-spectrum penicillin for respiratory, urinary, and dental infections, but causes a characteristic maculopapular rash in EBV/glandular fever that is not true allergy." + }, + { + "label": "Avoid / Cautions", + "value": "History of Type 1 (IgE) penicillin hypersensitivity. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Immunological: IgE-mediated anaphylaxis, angioedema. MODERATE — Non-allergic maculopapular rash. Gastrointestinal: Diarrhea, nausea. MODERATE — C. difficile infection. Renal: Crystalluria at massive IV doses." + }, + { + "label": "Key Interactions", + "value": "Allopurinol (Concurrent use massively increases the risk of a severe skin rash). Methotrexate (Penicillins reduce renal clearance of MTX, risking fatal bone marrow toxicity)." + }, + { + "label": "Monitoring", + "value": "Observe for 30 mins after first dose for signs of anaphylaxis. Check **eGFR** to guide dosing frequency." + }, + { + "label": "Clinical Pearl", + "value": "Giving amoxicillin to a patient with infectious mononucleosis (glandular fever) guarantees a severe, full-body maculopapular rash in 90% of cases. This is NOT a true allergy, but it will be labeled as one forever." + } + ] + }, + { + "slug": "amoxicillin-clavulanate", + "name": "Amoxicillin/clavulanate", + "class": "Antibiotic", + "subclass": "Penicillin + Beta-Lactamase Inhibitor", + "category": "Infectious Diseases - Penicillins", + "accent": "#ea580c", + "tag": "BETA-LACTAM", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "875/125 mg BD", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1 h", + "cls": "", + "flag": "" + }, + { + "label": "Hepatotoxicity", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Diarrhea", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Amoxicillin paired with clavulanic acid to overcome beta-lactamase producing bacteria. The go-to for animal/human bites and mixed intra-abdominal infections.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **875/125 mg BD** (Oral).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The clavulanate component is notoriously hepatotoxic. Avoid courses longer than 10-14 days.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Amoxicillin/clavulanate is the standard beta-lactamase-stable penicillin for resistant RTIs, UTIs, and bite wounds, but the clavulanate component frequently causes diarrhoea and hepatotoxicity risk increases with prolonged use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Hepatic", + "val": "HIGH — Cholestatic jaundice and hepatitis. Risk increases sharply with age and courses > 14 days.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe diarrhea, nausea, C. difficile infection.", + "tags": [] + }, + { + "key": "Immunological", + "val": "CRITICAL — Anaphylaxis (cross-reactive with all penicillins).", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "caution", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Animal / Human Bites", + "val": "**PO** 500/125 mg **BD** or **TDS**.", + "tags": [] + }, + { + "key": "Severe Respiratory / Intra-abdominal", + "val": "**PO** 875/125 mg **BD**. OR **IV** 1.2 g q8h.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Avoid the 875/125 mg tablet if **eGFR** < 30. Use 500/125 mg instead.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Augmentin, Curam", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (500/125 mg, 875/125 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoule (1 g/200 mg) for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for specific indications.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Bite wounds, severe exacerbations of COPD, diabetic foot infections.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Essential step-up when beta-lactamase resistance is suspected (e.g., H. influenzae, M. catarrhalis, S. aureus).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of Augmentin-associated jaundice/hepatic dysfunction or severe penicillin allergy.", + "tags": [], + "patient": { + "factors": ["hepatic", "allergy-pcn"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1. Generally acceptable when indicated; avoid unnecessary late-pregnancy/prolonged use and use only when benefits outweigh neonatal GI-risk concerns.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Amoxicillin/clavulanate pregnancy row is a source-backed benefit-risk caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Increases toxicity of Methotrexate (reduced renal clearance).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "MODERATE — Can prolong INR in patients on Warfarin.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Monitor **LFTs** if therapy extends beyond 7-10 days.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Warn patients to report dark urine, pale stools, or yellow sclera even *after* stopping the drug.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Clavulanate Ceiling", + "val": "If you need more amoxicillin, add plain amoxicillin. Never prescribe Augmentin 'TDS' if using the 875/125mg tablets—doubling the dose doubles the clavulanate, triggering massive diarrhea and severe hepatotoxicity.", + "tags": [] + }, + { + "key": "Delayed Jaundice", + "val": "Augmentin-induced cholestatic jaundice often presents 2 to 6 weeks AFTER the patient has finished the antibiotic course. Always check recent prescribing history in a new jaundiced patient.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Clavulanate acts as a 'decoy' suicide inhibitor, permanently binding beta-lactamase enzymes, leaving the amoxicillin free to destroy the bacterial cell wall.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1 hour (Both components renally cleared).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - AUGMENTIN DUO FORTE ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Penicillin + Beta-Lactamase Inhibitor — Amoxicillin paired with clavulanic acid to overcome beta-lactamase producing bacteria." + }, + { + "label": "Route / Formulation", + "value": "Tablets (500/125 mg, 875/125 mg). (Augmentin, Curam)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 500/125 mg **BD** or **TDS**. Max **875/125 mg BD** (Oral)." + }, + { + "label": "Key Indication Doses", + "value": "Animal / Human Bites: **PO** 500/125 mg **BD** or **TDS**. Severe Respiratory / Intra-abdominal: **PO** 875/125 mg **BD**. OR **IV** 1.2 g q8h. Renal Impairment: Avoid the 875/125 mg tablet if **eGFR** < 30. Use 500/125 mg instead." + }, + { + "label": "Best Uses", + "value": "Amoxicillin/clavulanate is the standard beta-lactamase-stable penicillin for resistant RTIs, UTIs, and bite wounds, but the clavulanate component frequently causes diarrhoea and hepatotoxicity risk increases with prolonged use." + }, + { + "label": "Avoid / Cautions", + "value": "History of Augmentin-associated jaundice/hepatic dysfunction or severe penicillin allergy. **Pregnancy** Category B1 (Generally safe, but avoid close to term due to theoretical necrotising enterocolitis risk in neonate)." + }, + { + "label": "Key Risks", + "value": "Hepatic: Cholestatic jaundice and hepatitis. Risk increases sharply with age and courses > 14 days. Gastrointestinal: Severe diarrhea, nausea, C. difficile infection. Immunological: Anaphylaxis (cross-reactive with all penicillins)." + }, + { + "label": "Key Interactions", + "value": "Increases toxicity of Methotrexate (reduced renal clearance). Can prolong INR in patients on Warfarin." + }, + { + "label": "Monitoring", + "value": "Monitor **LFTs** if therapy extends beyond 7-10 days. Warn patients to report dark urine, pale stools, or yellow sclera even *after* stopping the drug." + }, + { + "label": "Clinical Pearl", + "value": "If you need more amoxicillin, add plain amoxicillin. Never prescribe Augmentin 'TDS' if using the 875/125mg tablets—doubling the dose doubles the clavulanate, triggering massive diarrhea and severe hepatotoxicity." + } + ] + }, + { + "slug": "benzathine-benzylpenicillin", + "name": "Benzathine benzylpenicillin", + "class": "Antibiotic", + "subclass": "Long-acting Penicillin", + "category": "Infectious Diseases - Penicillins", + "accent": "#ea580c", + "tag": "BETA-LACTAM", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "2.4 MU STAT", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Duration", + "value": "2-4 WEEKS", + "cls": "good", + "flag": "" + }, + { + "label": "Route", + "value": "IM ONLY", + "cls": "purple", + "flag": "warn" + }, + { + "label": "IV Route", + "value": "FATAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "An extremely long-acting, highly insoluble depot formulation of Penicillin G. Slowly leaches into the blood over weeks to provide low-level, continuous bactericidal cover.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2.4 Million Units** (MU) per dose.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must NEVER be given IV. Accidental IV injection of this thick, milky suspension causes instant fatal cardiopulmonary arrest and microembolization.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Benzathine benzylpenicillin is the gold-standard IM depot penicillin for rheumatic fever prophylaxis and syphilis, but must never be given IV (fatal embolic reaction) and IM injection is painful.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Tissue", + "val": "HIGH — Exquisitely painful injection. Can cause severe sterile abscesses or nerve damage if not given deeply into a large muscle mass.", + "tags": [] + }, + { + "key": "Immunological", + "val": "CRITICAL — Anaphylaxis (and if it occurs, the depot continues releasing drug for weeks!).", + "tags": [] + }, + { + "key": "Systemic", + "val": "HIGH — Jarisch-Herxheimer reaction (fever, chills, myalgia within 24h of treating syphilis due to massive bacterial die-off).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Early Syphilis", + "val": "**IM** 1.8 g (2.4 MU) STAT as a single deep intramuscular injection.", + "tags": [] + }, + { + "key": "Late Latent Syphilis", + "val": "**IM** 1.8 g (2.4 MU) ONCE WEEKLY for 3 weeks.", + "tags": [] + }, + { + "key": "Rheumatic Fever Prophylaxis", + "val": "**IM** 900 mg (1.2 MU) every 3-4 weeks.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Bicillin L-A", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled syringe (1.2 MU / 900 mg) for deep **IM** injection ONLY. Store in the fridge.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Syphilis (all stages except neurosyphilis), secondary prophylaxis of rheumatic fever.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The absolute gold standard for Syphilis. Unmatched efficacy; overcomes patient non-compliance by requiring only 1-3 injections.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Intravenous administration. Severe penicillin allergy.", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. Mandatory treatment to prevent congenital syphilis.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Benzathine benzylpenicillin pregnancy row is Category A/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "LOW — Extremely low systemic blood levels mean drug interactions are virtually non-existent.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Aspirate the syringe prior to injection. If blood appears, withdraw completely and discard the syringe. Do not inject into a blood vessel.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Warn patients treating syphilis about the Jarisch-Herxheimer reaction (it is not an allergy; treat with Paracetamol).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Bicillin Confusion", + "val": "Do NOT confuse Bicillin L-A (Long-Acting Benzathine) with Bicillin C-R (Combo of Benzathine and Procaine). Bicillin C-R has a much shorter duration and is completely inadequate for treating Syphilis. Always double-check the box!", + "tags": [] + }, + { + "key": "The Warm-Up", + "val": "The pre-filled syringe is kept in the fridge and is incredibly thick. Take it out 30 mins before injection and roll it between your hands to warm it; this reduces the excruciating pain for the patient.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds PBPs, inhibiting cell wall synthesis. Its extreme insolubility in tissue fluid creates a physical depot that releases penicillin G continuously.", + "tags": [] + }, + { + "key": "Onset", + "val": "Hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "2-4 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Absorption half-life from the depot is ~14 days.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - BICILLIN L-A ARTG/PI, shortage notice, and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Long-acting Penicillin — An extremely long-acting, highly insoluble depot formulation of Penicillin G." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled syringe (1.2 MU / 900 mg) for deep **IM** injection ONLY. Store in the fridge. (Bicillin L-A)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 1.8 g (2.4 MU) STAT as a single deep intramuscular injection. Max **2.4 Million Units** (MU) per dose." + }, + { + "label": "Key Indication Doses", + "value": "Early Syphilis: **IM** 1.8 g (2.4 MU) STAT as a single deep intramuscular injection. Late Latent Syphilis: **IM** 1.8 g (2.4 MU) ONCE WEEKLY for 3 weeks. Rheumatic Fever Prophylaxis: **IM** 900 mg (1.2 MU) every 3-4 weeks." + }, + { + "label": "Best Uses", + "value": "Benzathine benzylpenicillin is the gold-standard IM depot penicillin for rheumatic fever prophylaxis and syphilis, but must never be given IV (fatal embolic reaction) and IM injection is painful." + }, + { + "label": "Avoid / Cautions", + "value": "Intravenous administration. Severe penicillin allergy. **Pregnancy** Category A. Mandatory treatment to prevent congenital syphilis." + }, + { + "label": "Key Risks", + "value": "Tissue: Exquisitely painful injection. Can cause severe sterile abscesses or nerve damage if not given deeply into a large muscle mass. Immunological: Anaphylaxis (and if it occurs, the depot continues releasing drug for weeks!). Systemic: Jarisch-Herxheimer reaction (fever, chills, myalgia within 24h of treating syphilis due to massive bacterial die-off)." + }, + { + "label": "Key Interactions", + "value": "Extremely low systemic blood levels mean drug interactions are virtually non-existent." + }, + { + "label": "Monitoring", + "value": "Aspirate the syringe prior to injection. If blood appears, withdraw completely and discard the syringe. Do not inject into a blood vessel. Warn patients treating syphilis about the Jarisch-Herxheimer reaction (it is not an allergy; treat with Paracetamol)." + }, + { + "label": "Clinical Pearl", + "value": "Do NOT confuse Bicillin L-A (Long-Acting Benzathine) with Bicillin C-R (Combo of Benzathine and Procaine). Bicillin C-R has a much shorter duration and is completely inadequate for treating Syphilis. Always double-check the box!" + } + ] + }, + { + "slug": "dicloxacillin", + "name": "Dicloxacillin", + "class": "Antibiotic", + "subclass": "Antistaphylococcal Penicillin", + "category": "Infectious Diseases - Penicillins", + "accent": "#ea580c", + "tag": "BETA-LACTAM", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "4 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1 h", + "cls": "", + "flag": "" + }, + { + "label": "Empty Stomach", + "value": "MANDATORY", + "cls": "good", + "flag": "" + }, + { + "label": "Hepatotoxicity", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Narrow-spectrum, oral anti-staphylococcal penicillin. The direct oral equivalent to IV Flucloxacillin for MSSA skin and soft tissue infections.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 g/day** (e.g., 1 g QID).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Terrible oral bioavailability if taken with food. Must be taken on a strictly empty stomach.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dicloxacillin is an oral antistaphylococcal penicillin alternative to flucloxacillin, but has the same hepatotoxicity risk and must be taken on an empty stomach for adequate absorption.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Hepatic", + "val": "HIGH — Cholestatic jaundice and hepatitis. Risk is highest in older adults (>55 years) and with prolonged courses (>14 days).", + "tags": [], + "patient": { + "factors": ["hepatic", "elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, abdominal pain, C. diff diarrhea.", + "tags": [] + }, + { + "key": "Immunological", + "val": "CRITICAL — Anaphylaxis, hypersensitivity rash.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Skin / Soft Tissue Infection", + "val": "**PO** 500 mg **QID** (1 hour before or 2 hours after meals).", + "tags": [] + }, + { + "key": "Severe Osteomyelitis (Step-down)", + "val": "**PO** 1 g **QID** (Requires extremely high doses to penetrate bone).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "SAFE — No dose adjustment required in mild-moderate CKD due to heavy hepatic clearance.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Diclocil", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (250 mg, 500 mg). Large capsules, notoriously foul-tasting if they burst.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Cellulitis, impetigo, mastitis, MSSA step-down therapy.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Often chosen over Flucloxacillin PO in some regions due to slightly better oral absorption, but carries the exact same clinical rules.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of dicloxacillin/flucloxacillin-induced liver injury or severe penicillin allergy.", + "tags": [], + "patient": { + "factors": ["hepatic", "allergy-pcn"], + "action": "contraindication", + "severity": "danger", + "note": "Avoid dicloxacillin after dicloxacillin/flucloxacillin liver injury or severe penicillin allergy." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Dicloxacillin pregnancy row is Category B1/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Food severely impairs absorption.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Probenecid blocks renal tubular secretion, doubling blood levels (often used intentionally in bone infections).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Monitor **LFTs** if the patient is on a prolonged course (e.g., 6 weeks for osteomyelitis).", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Ensure strict education regarding empty stomach administration.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Late Jaundice", + "val": "Like Augmentin and Flucloxacillin, Dicloxacillin can cause severe cholestatic jaundice up to 2 months AFTER the patient has finished the antibiotics. Warn patients to watch out for dark urine or yellow eyes post-treatment.", + "tags": [] + }, + { + "key": "The Mastitis Rule", + "val": "It is the drug of choice for lactating women with infective mastitis (usually caused by Staph aureus). It is safe for the breastfeeding infant.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Bactericidal. Resistant to destruction by staphylococcal beta-lactamase (penicillinase). Halts cell wall synthesis.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1 hour. Highly protein bound (97%).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DICLOXACILLIN VIATRIS/ARX ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Antistaphylococcal Penicillin — Narrow-spectrum, oral anti-staphylococcal penicillin." + }, + { + "label": "Route / Formulation", + "value": "Capsules (250 mg, 500 mg). Large capsules, notoriously foul-tasting if they burst. (Diclocil)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 500 mg **QID** (1 hour before or 2 hours after meals). Max **4 g/day** (e.g., 1 g QID)." + }, + { + "label": "Key Indication Doses", + "value": "Skin / Soft Tissue Infection: **PO** 500 mg **QID** (1 hour before or 2 hours after meals). Severe Osteomyelitis (Step-down): **PO** 1 g **QID** (Requires extremely high doses to penetrate bone). Renal Impairment: No dose adjustment required in mild-moderate CKD due to heavy hepatic clearance." + }, + { + "label": "Best Uses", + "value": "Dicloxacillin is an oral antistaphylococcal penicillin alternative to flucloxacillin, but has the same hepatotoxicity risk and must be taken on an empty stomach for adequate absorption." + }, + { + "label": "Avoid / Cautions", + "value": "History of Dicloxacillin/Flucloxacillin-induced liver injury. Severe penicillin allergy. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Hepatic: Cholestatic jaundice and hepatitis. Risk is highest in older adults (>55 years) and with prolonged courses (>14 days). Gastrointestinal: Nausea, abdominal pain, C. diff diarrhea. Immunological: Anaphylaxis, hypersensitivity rash." + }, + { + "label": "Key Interactions", + "value": "Food severely impairs absorption. Probenecid blocks renal tubular secretion, doubling blood levels (often used intentionally in bone infections)." + }, + { + "label": "Monitoring", + "value": "Monitor **LFTs** if the patient is on a prolonged course (e.g., 6 weeks for osteomyelitis). Ensure strict education regarding empty stomach administration." + }, + { + "label": "Clinical Pearl", + "value": "Like Augmentin and Flucloxacillin, Dicloxacillin can cause severe cholestatic jaundice up to 2 months AFTER the patient has finished the antibiotics. Warn patients to watch out for dark urine or yellow eyes post-treatment." + } + ] + }, + { + "slug": "flucloxacillin", + "name": "Flucloxacillin", + "class": "Antibiotic", + "subclass": "Antistaphylococcal Penicillin", + "category": "Infectious Diseases - Penicillins", + "accent": "#ea580c", + "tag": "BETA-LACTAM", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "8 g/day (IV)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1 h", + "cls": "", + "flag": "" + }, + { + "label": "Phlebitis", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Empty Stomach", + "value": "MANDATORY", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Narrow-spectrum, highly potent anti-staphylococcal penicillin. The definitive first-line treatment for MSSA bacteremia and severe cellulitis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **8 g/day** (**IV**) or **4 g/day** (**PO**).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Given IV, it destroys peripheral veins. Given PO, it has terrible bioavailability and MUST be taken on an empty stomach.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Flucloxacillin is the first-line antistaphylococcal penicillin for skin and soft tissue infections, but carries a significant risk of cholestatic hepatitis especially with courses > 14 days.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Tissue", + "val": "CRITICAL — Severe chemical phlebitis and vein thrombosis via peripheral IV.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "HIGH — Cholestatic hepatitis. Risk increases with age > 55 and courses > 14 days.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal", + "val": "MODERATE — Interstitial nephritis.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Cellulitis / MSSA Bacteremia", + "val": "**IV** 2 g q6h (8 g/day).", + "tags": [] + }, + { + "key": "Mild/Moderate Skin Infection", + "val": "**PO** 500 mg to 1 g **QID**. Strictly 1 hr before or 2 hrs after food.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce IV dose to 1 g q6h or q8h if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Flopen, Staphylex", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (250 mg, 500 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (1 g, 2 g) for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Skin and soft tissue infections, MSSA bacteremia/endocarditis, osteomyelitis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Unmatched efficacy against Methicillin-Susceptible S. aureus (MSSA). Superior to Vancomycin for MSSA.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of flucloxacillin-induced hepatic dysfunction, severe penicillin allergy.", + "tags": [], + "patient": { + "factors": ["hepatic", "allergy-pcn"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Flucloxacillin pregnancy row is Category B1/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Paracetamol. Co-administration of IV Flucloxacillin and high-dose Paracetamol in malnourished/elderly women can trigger severe High Anion Gap Metabolic Acidosis (HAGMA) due to 5-oxoproline accumulation.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Monitor **LFTs** regularly if used IV for prolonged periods (e.g., osteomyelitis).", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Inspect peripheral IV cannula sites strictly every shift for redness/pain.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Empty Stomach Rule", + "val": "Oral flucloxacillin absorption drops by 50% if taken with food. Ward nurses routinely give it with meals to prevent nausea, guaranteeing sub-therapeutic blood levels and clinical failure. Prescribe it exactly 1 hr before meals.", + "tags": [] + }, + { + "key": "The PICC Requirement", + "val": "If treating endocarditis or bone infections requiring 4-6 weeks of high-dose IV flucloxacillin, a PICC or central line is mandatory. It will obliterate peripheral veins within days.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Resistant to staphylococcal beta-lactamase. Binds PBPs to halt bacterial cell wall synthesis.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours. **IV** Immediate.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1 hour. Highly protein bound (95%).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - STAPHYLEX/FLUCLOXACILLIN ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Antistaphylococcal Penicillin — Narrow-spectrum, highly potent anti-staphylococcal penicillin." + }, + { + "label": "Route / Formulation", + "value": "Capsules (250 mg, 500 mg). (Flopen, Staphylex)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 2 g q6h (8 g/day). Max **8 g/day** (**IV**) or **4 g/day** (**PO**)." + }, + { + "label": "Key Indication Doses", + "value": "Severe Cellulitis / MSSA Bacteremia: **IV** 2 g q6h (8 g/day). Mild/Moderate Skin Infection: **PO** 500 mg to 1 g **QID**. Strictly 1 hr before or 2 hrs after food. Renal Impairment: Reduce IV dose to 1 g q6h or q8h if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Flucloxacillin is the first-line antistaphylococcal penicillin for skin and soft tissue infections, but carries a significant risk of cholestatic hepatitis especially with courses > 14 days." + }, + { + "label": "Avoid / Cautions", + "value": "History of flucloxacillin-induced hepatic dysfunction, severe penicillin allergy. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Tissue: Severe chemical phlebitis and vein thrombosis via peripheral IV. Hepatic: Cholestatic hepatitis. Risk increases with age > 55 and courses > 14 days. Renal: Interstitial nephritis." + }, + { + "label": "Key Interactions", + "value": "Paracetamol. Co-administration of IV Flucloxacillin and high-dose Paracetamol in malnourished/elderly women can trigger severe High Anion Gap Metabolic Acidosis (HAGMA) due to 5-oxoproline accumulation." + }, + { + "label": "Monitoring", + "value": "Monitor **LFTs** regularly if used IV for prolonged periods (e.g., osteomyelitis). Inspect peripheral IV cannula sites strictly every shift for redness/pain." + }, + { + "label": "Clinical Pearl", + "value": "Oral flucloxacillin absorption drops by 50% if taken with food. Ward nurses routinely give it with meals to prevent nausea, guaranteeing sub-therapeutic blood levels and clinical failure. Prescribe it exactly 1 hr before meals." + } + ] + }, + { + "slug": "phenoxymethylpenicillin", + "name": "Phenoxymethylpenicillin", + "class": "Antibiotic", + "subclass": "Penicillin V", + "category": "Infectious Diseases - Penicillins", + "accent": "#ea580c", + "tag": "BETA-LACTAM", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "3 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1 h", + "cls": "", + "flag": "" + }, + { + "label": "Food", + "value": "DECREASES ABSORPTION", + "cls": "warn", + "flag": "" + }, + { + "label": "Anaphylaxis", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Narrow-spectrum oral penicillin (Pen V). The absolute drug of choice for exquisitely sensitive Streptococcus pyogenes (Group A Strep).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **3 g/day** (e.g., 500 mg q4h to q6h in severe infections).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Has very poor oral bioavailability compared to Amoxicillin. Must be taken strictly on an empty stomach to achieve therapeutic blood levels.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Phenoxymethylpenicillin is the narrow-spectrum oral penicillin for streptococcal pharyngitis and rheumatic fever prophylaxis, but must be taken on an empty stomach and has limited gram-negative coverage.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Immunological", + "val": "CRITICAL — IgE-mediated anaphylaxis, angioedema. MODERATE — Non-allergic maculopapular rash.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, diarrhea (but lower C. diff risk than broad-spectrum agents).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Streptococcal Tonsillitis", + "val": "**PO** 500 mg **BD** for 10 days (to eradicate carriage and prevent Rheumatic Fever).", + "tags": [] + }, + { + "key": "Mild Cellulitis (Erysipelas)", + "val": "**PO** 500 mg **QID**.", + "tags": [] + }, + { + "key": "Rheumatic Fever Prophylaxis", + "val": "**PO** 250 mg **BD** (Often continued for years).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Cilicaine VK, Abbocillin-VK", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets/Capsules (250 mg, 500 mg). Oral liquid (125 mg/5mL, 250 mg/5mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Strep tonsillitis, erysipelas, prevention of rheumatic fever, post-splenectomy pneumococcal prophylaxis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly targeted, narrow-spectrum agent. Does NOT cover Gram-negatives or Staphylococcus aureus (unless proven sensitive).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of Type 1 (IgE) penicillin hypersensitivity.", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Phenoxymethylpenicillin pregnancy row is Category A/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Food drops absorption by up to 50%. Must take 1 hour before or 2 hours after meals.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Probenecid blocks renal excretion, doubling blood levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure strict adherence to the 10-day course for tonsillitis to prevent acute rheumatic fever and glomerulonephritis.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Compliance Trap", + "val": "Because it must be taken QID on an empty stomach for skin infections, compliance is historically terrible. If the patient is likely to fail this, switch to Amoxicillin (TDS, food independent) or Cephalexin.", + "tags": [] + }, + { + "key": "The Splenectomy Shield", + "val": "Patients without a spleen are highly susceptible to encapsulated bacteria. Lifelong daily Pen V is often prescribed to prevent overwhelming post-splenectomy infection (OPSI).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Bactericidal. Binds to penicillin-binding proteins (PBPs), halting peptidoglycan synthesis in the bacterial cell wall.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1 hour.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1 hour. Rapidly cleared by the kidneys.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CILICAINE VK ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Penicillin V — Narrow-spectrum oral penicillin (Pen V)." + }, + { + "label": "Route / Formulation", + "value": "Tablets/Capsules (250 mg, 500 mg). Oral liquid (125 mg/5mL, 250 mg/5mL). (Cilicaine VK, Abbocillin-VK)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 500 mg **BD** for 10 days (to eradicate carriage and prevent Rheumatic Fever). Max **3 g/day** (e.g., 500 mg q4h to q6h in severe infections)." + }, + { + "label": "Key Indication Doses", + "value": "Streptococcal Tonsillitis: **PO** 500 mg **BD** for 10 days (to eradicate carriage and prevent Rheumatic Fever). Mild Cellulitis (Erysipelas): **PO** 500 mg **QID**. Rheumatic Fever Prophylaxis: **PO** 250 mg **BD** (Often continued for years)." + }, + { + "label": "Best Uses", + "value": "Phenoxymethylpenicillin is the narrow-spectrum oral penicillin for streptococcal pharyngitis and rheumatic fever prophylaxis, but must be taken on an empty stomach and has limited gram-negative coverage." + }, + { + "label": "Avoid / Cautions", + "value": "History of Type 1 (IgE) penicillin hypersensitivity. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Immunological: IgE-mediated anaphylaxis, angioedema. MODERATE — Non-allergic maculopapular rash. Gastrointestinal: Nausea, diarrhea (but lower C. diff risk than broad-spectrum agents)." + }, + { + "label": "Key Interactions", + "value": "Food drops absorption by up to 50%. Must take 1 hour before or 2 hours after meals. Probenecid blocks renal excretion, doubling blood levels." + }, + { + "label": "Monitoring", + "value": "Ensure strict adherence to the 10-day course for tonsillitis to prevent acute rheumatic fever and glomerulonephritis. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Because it must be taken QID on an empty stomach for skin infections, compliance is historically terrible. If the patient is likely to fail this, switch to Amoxicillin (TDS, food independent) or Cephalexin." + } + ] + }, + { + "slug": "piperacillin-tazobactam", + "name": "Piperacillin/tazobactam", + "class": "Antibiotic", + "subclass": "Extended-spectrum Penicillin", + "category": "Infectious Diseases - Penicillins", + "accent": "#ea580c", + "tag": "BETA-LACTAM", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "18 g/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1 h", + "cls": "", + "flag": "" + }, + { + "label": "Nephrotoxic", + "value": "COMBINED RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Sodium Load", + "value": "HIGH", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-broad-spectrum anti-pseudomonal penicillin paired with a beta-lactamase inhibitor. The empirical backbone of severe hospital-acquired sepsis and neutropenic fever.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **18 g/day** (given as 4.5 g q6h).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Massive risk of Acute Kidney Injury (AKI) when combined with Vancomycin. Contains a massive sodium load that can exacerbate heart failure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Piperacillin/tazobactam is the workhorse broad-spectrum IV antibiotic for hospital-acquired and polymicrobial infections, but must not be combined with vancomycin via the same line and requires renal dose adjustment.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal", + "val": "CRITICAL — Acute Interstitial Nephritis and AKI. Risk skyrockets exponentially when co-administered with Vancomycin.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — C. difficile infection, severe diarrhea.", + "tags": [] + }, + { + "key": "Haematological", + "val": "MODERATE — Thrombocytopenia, neutropenia (with prolonged use > 14 days).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Sepsis / Neutropenic Fever", + "val": "**IV** 4.5 g q8h (standard) or 4.5 g q6h (Pseudomonas/critical illness).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Adjust dose frequency based on **eGFR**. e.g., 4.5 g q12h if **eGFR** < 20.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Tazocin", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (4 g piperacillin / 0.5 g tazobactam) for **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply. Restricted.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hospital-acquired pneumonia, complicated intra-abdominal sepsis, febrile neutropenia, diabetic foot infections.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "The definitive 'big gun' empiric beta-lactam on the ward. Tightly restricted by antimicrobial stewardship.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe penicillin allergy.", + "tags": [], + "patient": { + "factors": ["allergy-pcn"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Cardiovascular", + "val": "CAUTION — Congestive heart failure (due to high sodium load).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Piperacillin/tazobactam pregnancy row is Category B1/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Vancomycin. The combination 'Vanc/Taz' is notoriously nephrotoxic. Monitor creatinine daily.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Methotrexate (decreases clearance, risking fatal MTX toxicity).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Daily **U&E** and **eGFR** to track renal function. Check **FBC** weekly for bone marrow suppression.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor fluid balance and signs of fluid overload in cardiac patients.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Sodium Trap", + "val": "Each 4.5g vial of Tazocin contains ~9.4 mmol of sodium. A patient on q6h dosing receives nearly a liter of Normal Saline's worth of pure sodium every day, which can easily tip an elderly patient into acute pulmonary oedema.", + "tags": [] + }, + { + "key": "Extended Infusions", + "val": "Because beta-lactams depend on 'time above MIC', running a 4.5g dose slowly over 4 hours (extended infusion) provides vastly superior bacterial killing in severe sepsis compared to a 30-minute bolus.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Piperacillin halts cell wall synthesis. Tazobactam irreversibly inhibits beta-lactamases, protecting piperacillin. Excellent tissue penetration.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1 hour (Short half-life requires extended infusions or frequent dosing for efficacy).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - PIPERACILLIN/TAZOBACTAM KABI ARTG/PI and PBS check checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Extended-spectrum Penicillin — Ultra-broad-spectrum anti-pseudomonal penicillin paired with a beta-lactamase inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (4 g piperacillin / 0.5 g tazobactam) for **IV** infusion. (Tazocin)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 4.5 g q8h (standard) or 4.5 g q6h (Pseudomonas/critical illness). Max **18 g/day** (given as 4.5 g q6h)." + }, + { + "label": "Key Indication Doses", + "value": "Severe Sepsis / Neutropenic Fever: **IV** 4.5 g q8h (standard) or 4.5 g q6h (Pseudomonas/critical illness). Renal Impairment: Adjust dose frequency based on **eGFR**. e.g., 4.5 g q12h if **eGFR** < 20." + }, + { + "label": "Best Uses", + "value": "Piperacillin/tazobactam is the workhorse broad-spectrum IV antibiotic for hospital-acquired and polymicrobial infections, but must not be combined with vancomycin via the same line and requires renal dose adjustment." + }, + { + "label": "Avoid / Cautions", + "value": "Severe penicillin allergy. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Renal: Acute Interstitial Nephritis and AKI. Risk skyrockets exponentially when co-administered with Vancomycin. Gastrointestinal: C. difficile infection, severe diarrhea. Haematological: Thrombocytopenia, neutropenia (with prolonged use > 14 days)." + }, + { + "label": "Key Interactions", + "value": "Vancomycin. The combination 'Vanc/Taz' is notoriously nephrotoxic. Monitor creatinine daily. Methotrexate (decreases clearance, risking fatal MTX toxicity)." + }, + { + "label": "Monitoring", + "value": "Daily **U&E** and **eGFR** to track renal function. Check **FBC** weekly for bone marrow suppression. Monitor fluid balance and signs of fluid overload in cardiac patients." + }, + { + "label": "Clinical Pearl", + "value": "Each 4.5g vial of Tazocin contains ~9.4 mmol of sodium. A patient on q6h dosing receives nearly a liter of Normal Saline's worth of pure sodium every day, which can easily tip an elderly patient into acute pulmonary oedema." + } + ] + }, + { + "slug": "doxycycline", + "name": "Doxycycline", + "class": "Antibiotic", + "subclass": "Tetracycline", + "category": "Infectious Diseases - Tetracyclines", + "accent": "#ea580c", + "tag": "TETRACYCLINE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "200 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "18-22 h", + "cls": "", + "flag": "" + }, + { + "label": "Esophagitis", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Photosensitivity", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly lipophilic, broad-spectrum bacteriostatic tetracycline. Essential for atypical pneumonias, tick-borne diseases, and MRSA skin infections.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **200 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The capsule will ulcerate the esophagus if it gets stuck. Must take with a full glass of water and remain upright for 30 minutes.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Doxycycline is a versatile tetracycline for atypical infections, acne, and malaria prophylaxis, but causes severe photosensitivity, oesophageal ulceration (take upright with water), and is contraindicated in pregnancy.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Pill esophagitis, severe esophageal ulceration. HIGH — Nausea, vomiting (very common).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "HIGH — Photosensitivity (severe, rapid sunburns).", + "tags": [] + }, + { + "key": "Dental/Bone", + "val": "MODERATE — Tooth discoloration and enamel hypoplasia if given during tooth development.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "CAP / Atypicals / Cellulitis", + "val": "**PO** 100 mg **BD**.", + "tags": [] + }, + { + "key": "Malaria Prophylaxis", + "val": "**PO** 100 mg **OD** (Start 2 days before travel, continue 4 weeks after).", + "tags": [] + }, + { + "key": "Syphilis / Chlamydia", + "val": "**PO** 100 mg **BD** for 7-14 days.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Doxy, Vibramycin, Doxylin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets (50 mg, 100 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Atypical CAP, Rickettsia, Q fever, mild MRSA cellulitis, Chlamydia, acne.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Unmatched efficacy against tick-borne and atypical intracellular organisms.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Children < 8 years old (permanent tooth staining/bone effects).", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 8 + } + }, + "note": "Doxycycline is contraindicated/avoided in children younger than 8 years because of tooth and bone effects." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D (impairs fetal bone growth and stains teeth).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "SAFE — Doxycycline does not require renal dose adjustment in renal impairment.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "info", + "severity": "info", + "note": "Doxycycline generally does not require renal dose adjustment." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Chelates heavily with multivalent cations. Iron, Calcium, Magnesium (Antacids), and Dairy products will irreversibly bind Doxycycline in the gut, dropping absorption to zero. Separate by 2-4 hours.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Phenytoin and Carbamazepine induce Doxy metabolism, slashing its half-life to 7 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Counsel strictly: Take with a full glass of water, do not lie down for 30 mins, avoid direct sunlight, do not take with milk/iron.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Food Exception", + "val": "Historically, tetracyclines must be taken on an empty stomach. Doxycycline is the exception. Because it causes intense nausea, it *should* be taken with a meal (just not dairy) to improve tolerance without affecting absorption.", + "tags": [] + }, + { + "key": "The Dry Swallow Trap", + "val": "A young patient taking Doxycycline for acne right before bed without water will wake up 3 days later with agonizing retrosternal chest pain mimicking a heart attack. This is a severe esophageal chemical burn.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to the 30S ribosomal subunit, preventing addition of amino acids and halting bacterial protein synthesis (bacteriostatic).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "18-22 hours (Highly lipophilic, penetrates tissues and prostate beautifully. Excreted via feces).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DORYX doxycycline ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Tetracycline — Highly lipophilic, broad-spectrum bacteriostatic tetracycline." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets (50 mg, 100 mg). (Doxy, Vibramycin, Doxylin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 100 mg **BD**. Max **200 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "CAP / Atypicals / Cellulitis: **PO** 100 mg **BD**. Malaria Prophylaxis: **PO** 100 mg **OD** (Start 2 days before travel, continue 4 weeks after). Syphilis / Chlamydia: **PO** 100 mg **BD** for 7-14 days." + }, + { + "label": "Best Uses", + "value": "Doxycycline is a versatile tetracycline for atypical infections, acne, and malaria prophylaxis, but causes severe photosensitivity, oesophageal ulceration (take upright with water), and is contraindicated in pregnancy." + }, + { + "label": "Avoid / Cautions", + "value": "Children < 8 years old (permanent tooth staining). **Pregnancy** Category D (impairs fetal bone growth and stains teeth)." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Pill esophagitis, severe esophageal ulceration. HIGH — Nausea, vomiting (very common). Dermatological: Photosensitivity (severe, rapid sunburns). Dental/Bone: Tooth discoloration and enamel hypoplasia if given during tooth development." + }, + { + "label": "Key Interactions", + "value": "Chelates heavily with multivalent cations. Iron, Calcium, Magnesium (Antacids), and Dairy products will irreversibly bind Doxycycline in the gut, dropping absorption to zero. Separate by 2-4 hours. Phenytoin and Carbamazepine induce Doxy metabolism, slashing its half-life to 7 hours." + }, + { + "label": "Monitoring", + "value": "Counsel strictly: Take with a full glass of water, do not lie down for 30 mins, avoid direct sunlight, do not take with milk/iron. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Historically, tetracyclines must be taken on an empty stomach. Doxycycline is the exception. Because it causes intense nausea, it *should* be taken with a meal (just not dairy) to improve tolerance without affecting absorption." + } + ] + }, + { + "slug": "fosfomycin", + "name": "Fosfomycin", + "class": "Antibiotic", + "subclass": "Phosphonic Acid Derivative", + "category": "Infectious Diseases - Urinary Agents", + "accent": "#ea580c", + "tag": "ANTIBIOTIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "3 g STAT", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4 h", + "cls": "", + "flag": "" + }, + { + "label": "Freq", + "value": "SINGLE DOSE", + "cls": "good", + "flag": "" + }, + { + "label": "Pyelonephritis", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Unique bactericidal antibiotic that completely bypasses standard resistance mechanisms. Administered as a single, massive oral sachet. Exclusively treats uncomplicated cystitis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **3 g** (Given as a single, one-off STAT dose).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Do not use for pyelonephritis or systemic infections. It only concentrates in the bladder urine.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Fosfomycin is a single-dose oral antibiotic for uncomplicated UTIs including ESBL-producing organisms, but is only effective for lower UTIs and resistance can develop rapidly with repeated use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "MODERATE — Diarrhea, nausea, dyspepsia (very common, transient).", + "tags": [] + }, + { + "key": "Neurological", + "val": "LOW — Dizziness, headache.", + "tags": [] + }, + { + "key": "Immunological", + "val": "LOW — Rash.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Uncomplicated Cystitis (Females)", + "val": "**PO** 3 g STAT as a single dose. Dissolve the sachet in a glass of cold water. Take on an empty stomach before bed after emptying the bladder.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Avoid if **eGFR** < 30. It will not reach the bladder to kill the bacteria.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Monurol", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Granules for oral solution (3 g sachet). Orange/citrus flavored.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute uncomplicated lower urinary tract infections in females.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly effective 'last line' oral agent for highly resistant (ESBL/VRE) lower UTIs, preventing the need for IV admissions.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — **eGFR** < 30, severe systemic infection, pyelonephritis.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Avoid fosfomycin for severe renal impairment or upper/systemic UTI presentations." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B2. Safe and highly convenient for UTIs in pregnancy.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Fosfomycin pregnancy row is Category B2/source-reviewed safe-use context, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "MODERATE — Metoclopramide accelerates gastric emptying and drastically reduces the absorption of fosfomycin. Separate or avoid.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Educate the patient to take it AT NIGHT, after urinating. This allows the drug to sit undisturbed in the bladder pool overnight, maximizing bacterial killing time.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The ESBL Sniper", + "val": "When a urine culture returns an ESBL E. coli that is resistant to Trimethoprim, Cephalexin, and Augmentin, Fosfomycin is often the only oral sensitivity left. It saves the patient from a 5-day IV Meropenem admission.", + "tags": [] + }, + { + "key": "The Water Trap", + "val": "Must be dissolved in COLD water. Hot water degrades the active compound.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits the enzyme MurA, which catalyzes the very first step in bacterial peptidoglycan cell wall synthesis. Because it attacks step 1 (unlike penicillins which attack step 3), cross-resistance with other antibiotics is zero.", + "tags": [] + }, + { + "key": "Onset", + "val": "Hours. Rapidly concentrates in the urine.", + "tags": [] + }, + { + "key": "Duration", + "val": "Therapeutic urinary concentrations remain > 128 mg/L for 48-72 hours after a single dose!", + "tags": [] + }, + { + "key": "Half-life", + "val": "4 hours (in plasma, but stays in the bladder for days).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - MONUROL fosfomycin AusPAR/CMI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Phosphonic Acid Derivative — Unique bactericidal antibiotic that completely bypasses standard resistance mechanisms." + }, + { + "label": "Route / Formulation", + "value": "Granules for oral solution (3 g sachet). Orange/citrus flavored. (Monurol)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 3 g STAT as a single dose. Dissolve the sachet in a glass of cold water. Take on an empty stomach before bed after emptying the bladder. Max **3 g** (Given as a single, one-off STAT dose)." + }, + { + "label": "Key Indication Doses", + "value": "Uncomplicated Cystitis (Females): **PO** 3 g STAT as a single dose. Dissolve the sachet in a glass of cold water. Take on an empty stomach before bed after emptying the bladder. Renal Impairment: Avoid if **eGFR** < 30. It will not reach the bladder to kill the bacteria." + }, + { + "label": "Best Uses", + "value": "Fosfomycin is a single-dose oral antibiotic for uncomplicated UTIs including ESBL-producing organisms, but is only effective for lower UTIs and resistance can develop rapidly with repeated use." + }, + { + "label": "Avoid / Cautions", + "value": "**eGFR** < 30, severe systemic infection, pyelonephritis. **Pregnancy** Category B2. Safe and highly convenient for UTIs in pregnancy." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Diarrhea, nausea, dyspepsia (very common, transient). Neurological: Dizziness, headache. Immunological: Rash." + }, + { + "label": "Key Interactions", + "value": "Metoclopramide accelerates gastric emptying and drastically reduces the absorption of fosfomycin. Separate or avoid." + }, + { + "label": "Monitoring", + "value": "Educate the patient to take it AT NIGHT, after urinating. This allows the drug to sit undisturbed in the bladder pool overnight, maximizing bacterial killing time." + }, + { + "label": "Clinical Pearl", + "value": "When a urine culture returns an ESBL E. coli that is resistant to Trimethoprim, Cephalexin, and Augmentin, Fosfomycin is often the only oral sensitivity left. It saves the patient from a 5-day IV Meropenem admission." + } + ] + }, + { + "slug": "nitrofurantoin", + "name": "Nitrofurantoin", + "class": "Antibiotic", + "subclass": "Urinary Antiseptic", + "category": "Infectious Diseases - Urinary Agents", + "accent": "#ea580c", + "tag": "ANTIBIOTIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "20 mins", + "cls": "warn", + "flag": "" + }, + { + "label": "Lung Tox", + "value": "CHRONIC USE", + "cls": "hi", + "flag": "warn" + }, + { + "label": "eGFR < 30", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Urinary antiseptic. Rapidly concentrates in the bladder to kill E. coli. Useless for systemic infections. Highly effective for simple cystitis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mg/day** (100 mg QID for acute flares).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Completely ineffective if eGFR < 30 because it cannot reach the bladder. Long-term use causes fatal pulmonary fibrosis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Nitrofurantoin is a first-line antibiotic for uncomplicated lower UTIs with low resistance rates, but is contraindicated if eGFR < 30 and can cause pulmonary fibrosis with long-term use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory", + "val": "CRITICAL — Nitrofurantoin-induced pulmonary toxicity. Can be acute (hypersensitivity pneumonitis) or chronic (irreversible pulmonary fibrosis after ~6 months of use).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Peripheral neuropathy (especially in renal failure where the drug accumulates in the blood).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, vomiting, anorexia (take with food to mitigate).", + "tags": [] + }, + { + "key": "Haematological", + "val": "MODERATE — Hemolytic anemia (in G6PD deficiency).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Uncomplicated UTI", + "val": "**PO** 100 mg **QID** (or 100 mg **BD** for the modified-release macrocrystal form) for 5 days.", + "tags": [] + }, + { + "key": "UTI Prophylaxis", + "val": "**PO** 50-100 mg **NOCTE**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Avoid if **eGFR** < 30 (Drug pools in blood causing severe toxicity, and zero drug reaches the urine to kill the bacteria).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Macrodantin (IR), Macrobid (MR)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (50 mg, 100 mg). Take with food to boost absorption and reduce nausea.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute uncomplicated lower urinary tract infections (cystitis), prophylaxis of recurrent UTI.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line oral agent for female cystitis. Highly resistant to resistance-building.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal impairment, history of pulmonary toxicity, and late pregnancy/near term use.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Nitrofurantoin is contraindicated in severe renal impairment because toxicity rises and urinary efficacy falls." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category A (Safe in early pregnancy, but avoid at 38+ weeks due to risk of neonatal hemolytic anemia).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Nitrofurantoin pregnancy row is Category A with near-term avoidance, not a blanket pregnancy/paediatric/lactation contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Antacids containing magnesium delay absorption.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "LOW — Antagonises the action of nalidixic acid (rarely used).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **eGFR** before prescribing.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — For patients on chronic prophylaxis, review every 3-6 months. Ask about dry cough or shortness of breath (Pulmonary fibrosis).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Pyelonephritis Trap", + "val": "Nitrofurantoin does NOT penetrate renal tissue or blood. It only acts in the bladder pool. NEVER use it to treat pyelonephritis or urosepsis. The patient will die of sepsis while having sterile urine.", + "tags": [] + }, + { + "key": "Brown Urine", + "val": "Warn the patient that their urine will turn dark yellow or brown. It is harmless.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Reduced by bacterial flavoproteins to highly reactive intermediates that shatter bacterial ribosomes, DNA, and macromolecules.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours (Concentrates instantly in urine).", + "tags": [] + }, + { + "key": "Half-life", + "val": "20 minutes. Rapidly and exclusively cleared by the kidneys.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - MACRODANTIN nitrofurantoin ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Urinary Antiseptic — Urinary antiseptic." + }, + { + "label": "Route / Formulation", + "value": "Capsules (50 mg, 100 mg). Take with food to boost absorption and reduce nausea. (Macrodantin (IR), Macrobid (MR))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 100 mg **QID** (or 100 mg **BD** for the modified-release macrocrystal form) for 5 days. Max **400 mg/day** (100 mg QID for acute flares)." + }, + { + "label": "Key Indication Doses", + "value": "Acute Uncomplicated UTI: **PO** 100 mg **QID** (or 100 mg **BD** for the modified-release macrocrystal form) for 5 days. UTI Prophylaxis: **PO** 50-100 mg **NOCTE**. Renal Impairment: Avoid if **eGFR** < 30 (Drug pools in blood causing severe toxicity, and zero drug reaches the urine to kill the bacteria)." + }, + { + "label": "Best Uses", + "value": "Nitrofurantoin is a first-line antibiotic for uncomplicated lower UTIs with low resistance rates, but is contraindicated if eGFR < 30 and can cause pulmonary fibrosis with long-term use." + }, + { + "label": "Avoid / Cautions", + "value": "**eGFR** < 30, history of pulmonary toxicity, late pregnancy (near term). **Pregnancy** Category A (Safe in early pregnancy, but avoid at 38+ weeks due to risk of neonatal hemolytic anemia)." + }, + { + "label": "Key Risks", + "value": "Respiratory: Nitrofurantoin-induced pulmonary toxicity. Can be acute (hypersensitivity pneumonitis) or chronic (irreversible pulmonary fibrosis after ~6 months of use). Neurological: Peripheral neuropathy (especially in renal failure where the drug accumulates in the blood). Gastrointestinal: Nausea, vomiting, anorexia (take with food to mitigate). Haematological: Hemolytic anemia (in G6PD deficiency)." + }, + { + "label": "Key Interactions", + "value": "Antacids containing magnesium delay absorption. Antagonises the action of nalidixic acid (rarely used)." + }, + { + "label": "Monitoring", + "value": "Check **eGFR** before prescribing. For patients on chronic prophylaxis, review every 3-6 months. Ask about dry cough or shortness of breath (Pulmonary fibrosis)." + }, + { + "label": "Clinical Pearl", + "value": "Nitrofurantoin does NOT penetrate renal tissue or blood. It only acts in the bladder pool. NEVER use it to treat pyelonephritis or urosepsis. The patient will die of sepsis while having sterile urine." + } + ] + }, + { + "slug": "trimethoprim", + "name": "Trimethoprim", + "class": "Antibiotic", + "subclass": "Dihydrofolate Reductase Inhibitor", + "category": "Infectious Diseases - Urinary Agents", + "accent": "#ea580c", + "tag": "ANTIBIOTIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "8-10 h", + "cls": "", + "flag": "" + }, + { + "label": "Hyperkalemia", + "value": "RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Creatinine", + "value": "ARTIFICIAL BUMP", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Folate antagonist. Used as monotherapy exclusively for uncomplicated UTIs. Avoids the severe skin/sulfa toxicities of Bactrim (Co-trimoxazole).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Blocks potassium excretion. Extremely dangerous if given to elderly patients on ACEi/ARBs or Spironolactone.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Trimethoprim is a simple first-line antibiotic for uncomplicated UTIs, but causes hyperkalaemia (especially with ACEi/ARBs), falsely elevates creatinine, and folate antagonism limits use in pregnancy.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal & Electrolytes", + "val": "HIGH — Hyperkalemia (acts like a potassium-sparing diuretic in the distal tubule). Artificial elevation of serum creatinine.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea, vomiting, glossitis.", + "tags": [] + }, + { + "key": "Haematological", + "val": "MODERATE — Bone marrow depression, megaloblastic anemia (due to folate blockade, mostly with prolonged use).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Uncomplicated UTI", + "val": "**PO** 300 mg **OD** at night for 3-5 days.", + "tags": [] + }, + { + "key": "UTI Prophylaxis", + "val": "**PO** 150 mg **NOCTE**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Halve the dose if **eGFR** < 30. Avoid if **eGFR** < 15.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Alprim, Triprim", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (300 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute uncomplicated lower UTI, prophylaxis of recurrent UTI.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line oral agent for cystitis alongside Nitrofurantoin and Cephalexin.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal impairment without dose adjustment, megaloblastic anemia from folate deficiency.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category B3. Strictly avoid in 1st trimester as it blocks folate, massively increasing the risk of neural tube defects (spina bifida).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — ACEi, ARBs, Spironolactone. The combination guarantees hyperkalemia in the elderly. Check K+ levels.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Methotrexate. Co-administration causes fatal bone marrow failure.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **U&E** (potassium) if the patient is elderly or on RAAS blockers.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "Ensure the patient is not taking over-the-counter K+ supplements.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Fake AKI", + "val": "Trimethoprim competitively blocks the exact same tubular transporter that secretes creatinine. Blood creatinine will artificially rise by ~20% within days. This is a harmless lab artefact. If the Urea is normal and K+ is stable, do not panic and diagnose AKI.", + "tags": [] + }, + { + "key": "The Prostate Penetrator", + "val": "Because it is highly lipid-soluble, Trimethoprim penetrates the prostate gland brilliantly. It is highly effective for bacterial prostatitis (unlike Nitrofurantoin or Penicillins).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Reversibly inhibits bacterial dihydrofolate reductase (DHFR), preventing the synthesis of tetrahydrofolic acid (active folate), halting DNA synthesis. Bacteriostatic.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "8-10 hours. Concentrates highly in the urine and prostate.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TRIMETHOPRIM VIATRIS ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Dihydrofolate Reductase Inhibitor — Folate antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (300 mg). (Alprim, Triprim)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 300 mg **OD** at night for 3-5 days. Max **300 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Acute Uncomplicated UTI: **PO** 300 mg **OD** at night for 3-5 days. UTI Prophylaxis: **PO** 150 mg **NOCTE**. Renal Impairment: Halve the dose if **eGFR** < 30. Avoid if **eGFR** < 15." + }, + { + "label": "Best Uses", + "value": "Trimethoprim is a simple first-line antibiotic for uncomplicated UTIs, but causes hyperkalaemia (especially with ACEi/ARBs), falsely elevates creatinine, and folate antagonism limits use in pregnancy." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal impairment without dose adjustment, megaloblastic anemia from folate deficiency. **Pregnancy** Category B3. Strictly avoid in 1st trimester as it blocks folate, massively increasing the risk of neural tube defects (spina bifida)." + }, + { + "label": "Key Risks", + "value": "Renal & Electrolytes: Hyperkalemia (acts like a potassium-sparing diuretic in the distal tubule). Artificial elevation of serum creatinine. Gastrointestinal: Nausea, vomiting, glossitis. Haematological: Bone marrow depression, megaloblastic anemia (due to folate blockade, mostly with prolonged use)." + }, + { + "label": "Key Interactions", + "value": "ACEi, ARBs, Spironolactone. The combination guarantees hyperkalemia in the elderly. Check K+ levels. Methotrexate. Co-administration causes fatal bone marrow failure." + }, + { + "label": "Monitoring", + "value": "**U&E** (potassium) if the patient is elderly or on RAAS blockers. Ensure the patient is not taking over-the-counter K+ supplements." + }, + { + "label": "Clinical Pearl", + "value": "Trimethoprim competitively blocks the exact same tubular transporter that secretes creatinine. Blood creatinine will artificially rise by ~20% within days. This is a harmless lab artefact. If the Urea is normal and K+ is stable, do not panic and diagnose AKI." + } + ] + }, + { + "slug": "allopurinol", + "name": "Allopurinol", + "class": "Gout", + "subclass": "Xanthine Oxidase Inhibitor", + "category": "Musculoskeletal & Rheumatology", + "accent": "#be123c", + "tag": "URATE LOWERING", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "900 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "15 h (Act: 15h)", + "cls": "", + "flag": "" + }, + { + "label": "Acute Gout", + "value": "FLARE RISK", + "cls": "warn", + "flag": "" + }, + { + "label": "SJS/TEN", + "value": "HLA-B*5801", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Xanthine oxidase inhibitor. The first-line urate-lowering therapy (ULT) to shrink tophi and prevent recurrent gout attacks.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **900 mg/day** (Requires specialist oversight. Standard is 100-300 mg/day).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Starting allopurinol dissolves crystal stores, which causes *massive* acute gout flares. Must co-prescribe colchicine/NSAIDs for the first 3-6 months.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Allopurinol is first-line urate-lowering therapy for chronic gout prevention. Start low, titrate to serum urate target, and use flare prophylaxis when initiating.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Dermatological / Immuno", + "val": "CRITICAL — Allopurinol Hypersensitivity Syndrome (AHS), severe rash, Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN).", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "HIGH — Paradoxical acute gout flares upon initiation.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "MODERATE — Transaminitis, hepatotoxicity.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Chronic Gout Prophylaxis", + "val": "Start **PO** 100 mg **OD**. Titrate up by 100 mg every 2-4 weeks until serum urate < 0.36 mmol/L.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Start lower and titrate more slowly in renal impairment; monitor renal function and toxicity, but titrate to urate target under review.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Allopurinol requires lower starting dose, slower titration, and monitoring in renal impairment." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zyloprim, Progout", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (100 mg, 300 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention of gout flares, uric acid nephropathy, tumor lysis syndrome.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The foundational chronic therapy for gout. Stops uric acid production at the source.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known HLA-B*58:01 allele (Massive risk of SJS/TEN).", + "tags": [] + }, + { + "key": "Acute Gout", + "val": "CAUTION — Historically, starting it during an acute attack was contraindicated. Modern guidelines say it is safe to start *during* an attack provided the patient is covered with Colchicine/NSAIDs.", + "tags": [], + "patient": { + "factors": ["allergy-nsaid"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Azathioprine and 6-Mercaptopurine. Xanthine oxidase breaks down these immunosuppressants. Allopurinol blocks this, causing 1000x fatal bone marrow toxicity. Do NOT combine without oncology oversight.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Amoxicillin/Ampicillin (massive increase in non-allergic maculopapular rash).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Serum uric acid (target < 0.36 mmol/L or < 0.30 if tophi present). Baseline **eGFR** and **LFTs**.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Educate the patient to stop the drug immediately and present to ED if ANY skin rash or oral blisters develop.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Flare Trap", + "val": "If you give a patient Allopurinol without Colchicine cover, they will get a horrific gout flare in week 2, assume the drug is making them worse, and stop taking it forever. Always cover them.", + "tags": [] + }, + { + "key": "The Asian Demographic", + "val": "The HLA-B*5801 gene (which guarantees fatal SJS) is highly prevalent in Han Chinese, Korean, and Thai populations. Pharmacogenetic screening is highly recommended before starting Allopurinol in these demographics.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Purine analog. Competitively inhibits Xanthine Oxidase, the enzyme that converts hypoxanthine/xanthine into uric acid. Lowers blood and urine uric acid levels.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Urate normalises in 1-3 weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "15 hours (Active metabolite oxypurinol is renally cleared and dictates toxicity).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: PROGOUT/ZYLOPRIM allopurinol Australian PI/CMI and gout guidance source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Xanthine Oxidase Inhibitor — Xanthine oxidase inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (100 mg, 300 mg). (Zyloprim, Progout)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 100 mg **OD**. Titrate up by 100 mg every 2-4 weeks until serum urate < 0.36 mmol/L. Max **900 mg/day** (Requires specialist oversight. Standard is 100-300 mg/day)." + }, + { + "label": "Key Indication Doses", + "value": "Chronic Gout Prophylaxis: Start **PO** 100 mg **OD**. Titrate up by 100 mg every 2-4 weeks until serum urate < 0.36 mmol/L. Renal Impairment: Start at **PO** 50 mg **OD** or alternate days if **eGFR** < 30. Very slow titration required." + }, + { + "label": "Best Uses", + "value": "Allopurinol is first-line urate-lowering therapy for chronic gout prevention. Start low, titrate to serum urate target, and use flare prophylaxis when initiating; do not stop established allopurinol during an acute flare." + }, + { + "label": "Avoid / Cautions", + "value": "Known HLA-B*58:01 allele (Massive risk of SJS/TEN)." + }, + { + "label": "Key Risks", + "value": "Dermatological / Immuno: Allopurinol Hypersensitivity Syndrome (AHS), severe rash, Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN). Musculoskeletal: Paradoxical acute gout flares upon initiation. Hepatic: Transaminitis, hepatotoxicity." + }, + { + "label": "Key Interactions", + "value": "Azathioprine and 6-Mercaptopurine. Xanthine oxidase breaks down these immunosuppressants. Allopurinol blocks this, causing 1000x fatal bone marrow toxicity. Do NOT combine without oncology oversight. Amoxicillin/Ampicillin (massive increase in non-allergic maculopapular rash)." + }, + { + "label": "Monitoring", + "value": "Serum uric acid (target < 0.36 mmol/L or < 0.30 if tophi present). Baseline **eGFR** and **LFTs**. Educate the patient to stop the drug immediately and present to ED if ANY skin rash or oral blisters develop." + }, + { + "label": "Clinical Pearl", + "value": "If you give a patient Allopurinol without Colchicine cover, they will get a horrific gout flare in week 2, assume the drug is making them worse, and stop taking it forever. Always cover them." + } + ] + }, + { + "slug": "baclofen", + "name": "Baclofen", + "class": "Muscle Relaxant", + "subclass": "GABA-B Agonist", + "category": "Musculoskeletal & Rheumatology", + "accent": "#d97706", + "tag": "SPASMOLYTIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "100 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3-4 h", + "cls": "", + "flag": "" + }, + { + "label": "Withdrawal", + "value": "SEIZURE RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "MANDATORY", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Central muscle relaxant. Highly effective for spasticity originating from spinal cord or brain injury. Acts as a potent depressant on spinal reflexes.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **100 mg/day** (Requires very slow titration to prevent profound sedation/weakness).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Abrupt cessation causes severe, life-threatening withdrawal (seizures, hallucinations, hyperthermia). Must be tapered over weeks.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Baclofen is the first-line skeletal muscle relaxant for spasticity (MS, spinal cord injury), but causes significant sedation and abrupt withdrawal can cause life-threatening seizures and autonomic instability.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Seizures, acute psychosis, and hallucinations upon abrupt withdrawal. HIGH — Profound sedation, dizziness, severe hypotonia (muscle weakness making the patient unable to stand).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Hypotension.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Nausea (usually transient).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Chronic Spasticity", + "val": "Start **PO** 5 mg **TDS**. Titrate up by 15 mg/day every 3 days. Maintenance usually 30-75 mg/day. Max 100 mg/day.", + "tags": [] + }, + { + "key": "Intrathecal (Severe)", + "val": "Continuous infusion directly into the spinal fluid via an implanted pump (Specialist only).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Reduce dose to 5 mg/day if **eGFR** < 30. High risk of severe encephalopathy and coma.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lioresal, Clofen", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg, 25 mg). Oral liquid (5 mg/mL).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for Intrathecal injection/infusion ONLY. Never IV.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for specific neurological indications.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe muscle spasticity associated with MS, spinal cord injury, cerebral palsy, stroke.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Hiccups, severe alcohol cravings (high dose).", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The gold-standard oral anti-spasmodic for upper motor neuron lesions.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active peptic ulceration, severe psychosis/schizophrenia (can exacerbate).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Predominantly renally excreted; reduce dose and monitor closely in CKD/AKI. Severe renal impairment can cause profound encephalopathy/coma.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Baclofen accumulates in renal impairment and can cause severe encephalopathy or coma." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3; use only if benefit justifies risk and monitor neonate if used near delivery.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Baclofen in pregnancy requires benefit-risk review; neonatal effects are possible if used near delivery." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Extreme additive CNS depression and weakness if combined with Opioids, Benzodiazepines, or Alcohol.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Antihypertensives (Additive hypotension).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and routine **U&E** and **eGFR**.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Assess muscle tone. Over-treating spasticity will remove the 'stiffness' the patient relies on to stand up and walk, rendering them bedbound.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Intrathecal Pump Trap", + "val": "If an implanted intrathecal baclofen pump runs dry or the catheter snaps, the patient will be plunged into massive, fatal withdrawal within hours. This is a medical emergency requiring massive doses of oral baclofen or ICU sedation with diazepam/propofol until the pump is fixed.", + "tags": [] + }, + { + "key": "The CKD Coma", + "val": "A classic ward presentation: an MS patient with a UTI develops AKI, their Baclofen accumulates, and they are found comatose. Check renal function before giving Naloxone/Flumazenil.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Specific agonist at the GABA-B receptor in the spinal cord. Hyperpolarizes presynaptic nerve terminals, severely restricting the release of excitatory neurotransmitters (glutamate, aspartate), suppressing reflex arcs.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** Hours to days for full antispastic effect.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-4 hours (Rapidly and predominantly excreted unchanged by the kidneys).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: LIORESAL/baclofen Australian PI/CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "GABA-B Agonist — Central muscle relaxant." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg, 25 mg). Oral liquid (5 mg/mL). (Lioresal, Clofen)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 5 mg **TDS**. Titrate up by 15 mg/day every 3 days. Maintenance usually 30-75 mg/day. Max 100 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Chronic Spasticity: Start **PO** 5 mg **TDS**. Titrate up by 15 mg/day every 3 days. Maintenance usually 30-75 mg/day. Max 100 mg/day. Intrathecal (Severe): Continuous infusion directly into the spinal fluid via an implanted pump (Specialist only). Renal Impairment: Reduce dose to 5 mg/day if **eGFR** < 30. High risk of severe encephalopathy and coma." + }, + { + "label": "Best Uses", + "value": "Baclofen is the first-line skeletal muscle relaxant for spasticity (MS, spinal cord injury), but causes significant sedation and abrupt withdrawal can cause life-threatening seizures and autonomic instability." + }, + { + "label": "Avoid / Cautions", + "value": "Active peptic ulceration, severe psychosis/schizophrenia (can exacerbate). **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Neurological: Seizures, acute psychosis, and hallucinations upon abrupt withdrawal. HIGH — Profound sedation, dizziness, severe hypotonia (muscle weakness making the patient unable to stand). Cardiovascular: Hypotension. Gastrointestinal: Nausea (usually transient)." + }, + { + "label": "Key Interactions", + "value": "Extreme additive CNS depression and weakness if combined with Opioids, Benzodiazepines, or Alcohol. Antihypertensives (Additive hypotension)." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **U&E** and **eGFR**. Assess muscle tone. Over-treating spasticity will remove the 'stiffness' the patient relies on to stand up and walk, rendering them bedbound." + }, + { + "label": "Clinical Pearl", + "value": "If an implanted intrathecal baclofen pump runs dry or the catheter snaps, the patient will be plunged into massive, fatal withdrawal within hours. This is a medical emergency requiring massive doses of oral baclofen or ICU sedation with diazepam/propofol until the pump is fixed." + } + ] + }, + { + "slug": "colchicine", + "name": "Colchicine", + "class": "Gout", + "subclass": "Microtubule Inhibitor", + "category": "Musculoskeletal & Rheumatology", + "accent": "#be123c", + "tag": "ANTI-INFLAMMATORY", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1.5 mg/day (Acute)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "27-31 h", + "cls": "", + "flag": "" + }, + { + "label": "Diarrhea", + "value": "TOXICITY SIGN", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "MANDATORY", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ancient alkaloid derived from the autumn crocus. Highly specific anti-inflammatory for gout, acting as a direct mitotic/microtubule poison to neutrophils.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1.5 mg** on Day 1 for acute gout (e.g., 1 mg STAT, then 0.5 mg 1h later). Never exceed this. Old 'dose to diarrhea' regimens are lethal.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Extremely narrow therapeutic index. Fatal in overdose. Severe GI symptoms indicate toxicity.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Colchicine is a first-line treatment for acute gout flares and pericarditis, but has an extremely narrow therapeutic index with severe GI toxicity and fatal overdose potential.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Severe, watery diarrhea, severe nausea/vomiting. (These are the first signs of cellular toxicity, not just a 'side effect').", + "tags": [] + }, + { + "key": "Haematological", + "val": "HIGH — Bone marrow suppression (agranulocytosis, aplastic anemia) with high doses/chronic use.", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Neuromyopathy (especially if combined with statins).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Gout Flare", + "val": "**PO** 1 mg STAT, followed by 0.5 mg one hour later (Max 1.5 mg/day). Do not repeat course for at least 3 days.", + "tags": [] + }, + { + "key": "Gout Prophylaxis", + "val": "**PO** 0.5 mg **OD** or **BD** (while initiating Allopurinol).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — If **eGFR** < 30, use 0.5 mg STAT for acute flare. Do not use for daily prophylaxis.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lengout, Colgout", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (500 mcg / 0.5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute gout flares, gout prophylaxis, Familial Mediterranean Fever.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Acute pericarditis (reduces inflammation and recurrence).", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "First-line for acute gout if NSAIDs are contraindicated (e.g., renal failure, heart failure).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Serious renal, hepatic, gastrointestinal, cardiac, or blood disorder; combined renal/hepatic impairment with strong CYP3A4 or P-gp inhibitors.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Colchicine is contraindicated or high-risk in serious renal/hepatic impairment, especially with CYP3A4/P-gp inhibitors." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category D; use only with specialist benefit-risk review.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Colchicine pregnancy exposure requires specialist benefit-risk review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Macrolides (Clarithromycin), Azoles, and Verapamil/Diltiazem block CYP3A4/P-gp. Colchicine levels spike exponentially, causing fatal multi-organ failure. AVOID combination.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Statins (additive risk of severe myopathy/rhabdomyolysis).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Cease the drug IMMEDIATELY if the patient develops diarrhea or vomiting.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **U&E** and **eGFR** before initiating. Check **FBC** for chronic users.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Obsolete Rule", + "val": "Historically, doctors told patients to 'take a pill every hour until the pain stops or you get diarrhea'. This was poisoning the patient. The modern dose is 1.5mg TOTAL on day 1. It is equally effective and much safer.", + "tags": [] + }, + { + "key": "The Cell Poison", + "val": "Colchicine is essentially an oral chemotherapy agent (spindle poison). Treat it with immense respect. A mere 7 mg (14 tablets) can be a fatal overdose in an adult.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to tubulin, inhibiting microtubule polymerization. This paralyses neutrophil motility and phagocytosis, stopping them from attacking uric acid crystals and causing inflammation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 12-24 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "27-31 hours. Metabolised by CYP3A4 and cleared by P-glycoprotein.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: LENGOUT/COLGOUT colchicine Australian PI/CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Microtubule Inhibitor — Ancient alkaloid derived from the autumn crocus." + }, + { + "label": "Route / Formulation", + "value": "Tablets (500 mcg / 0.5 mg). (Lengout, Colgout)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1 mg STAT, followed by 0.5 mg one hour later (Max 1.5 mg/day). Do not repeat course for at least 3 days. Max **1.5 mg** on Day 1 for acute gout (e.g., 1 mg STAT, then 0.5 mg 1h later). Never exceed this. Old 'dose to diarrhea' regimens are lethal." + }, + { + "label": "Key Indication Doses", + "value": "Acute Gout Flare: **PO** 1 mg STAT, followed by 0.5 mg one hour later (Max 1.5 mg/day). Do not repeat course for at least 3 days. Gout Prophylaxis: **PO** 0.5 mg **OD** or **BD** (while initiating Allopurinol). Renal Impairment: If **eGFR** < 30, use 0.5 mg STAT for acute flare. Do not use for daily prophylaxis." + }, + { + "label": "Best Uses", + "value": "Colchicine is a first-line treatment for acute gout flares and pericarditis, but has an extremely narrow therapeutic index with severe GI toxicity and fatal overdose potential." + }, + { + "label": "Avoid / Cautions", + "value": "Combined severe renal and hepatic impairment. Concurrent use of strong CYP3A4/P-gp inhibitors in patients with renal/hepatic impairment. **Pregnancy** Category D (arrests cell division)." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe, watery diarrhea, severe nausea/vomiting. (These are the first signs of cellular toxicity, not just a 'side effect'). Haematological: Bone marrow suppression (agranulocytosis, aplastic anemia) with high doses/chronic use. Neurological: Neuromyopathy (especially if combined with statins)." + }, + { + "label": "Key Interactions", + "value": "Macrolides (Clarithromycin), Azoles, and Verapamil/Diltiazem block CYP3A4/P-gp. Colchicine levels spike exponentially, causing fatal multi-organ failure. AVOID combination. Statins (additive risk of severe myopathy/rhabdomyolysis)." + }, + { + "label": "Monitoring", + "value": "Cease the drug IMMEDIATELY if the patient develops diarrhea or vomiting. Check **U&E** and **eGFR** before initiating. Check **FBC** for chronic users." + }, + { + "label": "Clinical Pearl", + "value": "Historically, doctors told patients to 'take a pill every hour until the pain stops or you get diarrhea'. This was poisoning the patient. The modern dose is 1.5mg TOTAL on day 1. It is equally effective and much safer." + } + ] + }, + { + "slug": "dantrolene", + "name": "Dantrolene", + "class": "Antidote", + "subclass": "Ryanodine Antagonist", + "category": "Musculoskeletal & Rheumatology", + "accent": "#d97706", + "tag": "ANTIDOTE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/kg (IV Load)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4-8 h", + "cls": "", + "flag": "" + }, + { + "label": "Hepatotoxicity", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Muscle Weakness", + "value": "PROFOUND", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Direct-acting skeletal muscle relaxant. The absolute life-saving, definitive antidote for Malignant Hyperthermia (MH) and Neuroleptic Malignant Syndrome (NMS).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/kg** (IV for MH crisis). Oral max is 400 mg/day.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Directly paralyzes skeletal muscle. Causes profound, dose-dependent hepatotoxicity if used orally for chronic spasticity.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dantrolene is the only specific treatment for malignant hyperthermia and NMS, but causes hepatotoxicity requiring liver function monitoring and significant muscle weakness.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Hepatic", + "val": "CRITICAL — Fatal symptomatic hepatitis (especially in females > 35 years taking oral doses > 300 mg/day for chronic spasticity).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neuromuscular", + "val": "HIGH — Profound, generalized muscle weakness (can impair respiratory muscles and swallowing).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe diarrhea, nausea.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Malignant Hyperthermia (Crisis)", + "val": "**IV** 2.5 mg/kg STAT rapid push. Repeat 1 mg/kg every 5 mins until symptoms (rigidity/hypercarbia/fever) stop. Max 10 mg/kg.", + "tags": [] + }, + { + "key": "Neuroleptic Malignant Syndrome", + "val": "**IV** 1-2.5 mg/kg, or **PO** 50-200 mg/day in divided doses (Off-label, but standard of care).", + "tags": [] + }, + { + "key": "Chronic Spasticity (Oral)", + "val": "Start **PO** 25 mg **OD**. Titrate up weekly. Max 400 mg/day (rarely used due to liver toxicity).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dantrium", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (25 mg, 50 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (20 mg powder). Extremely difficult to dissolve. Requires massive volumes of sterile water (60 mL per vial) and intense shaking by multiple staff during a crisis.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital OT/ICU emergency supply.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Malignant Hyperthermia (triggered by volatile anaesthetics/suxamethonium), chronic severe spasticity.", + "tags": ["TGA"] + }, + { + "key": "Off-Label", + "val": "Neuroleptic Malignant Syndrome, severe MDMA/Amphetamine-induced hyperthermia/rigidity.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Emergency rescue drug stored in every operating theatre 'MH Cart'.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active liver disease for chronic oral use; no absolute contraindication should delay IV use for malignant hyperthermia emergency treatment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Chronic oral dantrolene is contraindicated/avoided in active liver disease." + } + }, + { + "key": "Cardiovascular", + "val": "CAUTION — Severely impaired cardiac/pulmonary function (weakness may precipitate failure).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Avoid calcium channel blockers with IV dantrolene because severe hyperkalaemia and cardiovascular collapse have been reported.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — For chronic oral use, baseline and frequent (monthly) **LFTs**. Stop immediately if transaminases rise. Check **U&E** (K+) and ABGs during acute crisis.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Continuous ICU-level monitoring (Core temp, ETCO2, **HR**, **BP**) during MH crisis.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Dissolving Nightmare", + "val": "Dantrolene powder is highly lipophilic and notoriously stubborn to dissolve in water. In an MH crisis, you need ~10 vials for an average adult. It takes multiple nurses furiously shaking 60mL syringes for minutes to prepare it. Newer formulations (Ryanodex) dissolve in 5mL instantly but are highly expensive.", + "tags": [] + }, + { + "key": "The NMS Overlap", + "val": "Neuroleptic Malignant Syndrome (caused by antipsychotics) and Malignant Hyperthermia (caused by anesthesia) look identical clinically (fever, rigidity, CK spike). Dantrolene effectively treats the muscle rigidity in both, preventing death from hyperthermia and rhabdomyolysis.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to the Ryanodine receptor (RyR1) on the sarcoplasmic reticulum inside skeletal muscle. Blocks the massive release of intracellular calcium, instantly halting uncontrolled muscle contraction and heat production.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Minutes. **PO** Hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "4-8 hours (Metabolised hepatically).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: DANTRIUM/dantrolene Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Ryanodine Antagonist — Direct-acting skeletal muscle relaxant." + }, + { + "label": "Route / Formulation", + "value": "Capsules (25 mg, 50 mg). (Dantrium)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 2.5 mg/kg STAT rapid push. Repeat 1 mg/kg every 5 mins until symptoms (rigidity/hypercarbia/fever) stop. Max 10 mg/kg." + }, + { + "label": "Key Indication Doses", + "value": "Malignant Hyperthermia (Crisis): **IV** 2.5 mg/kg STAT rapid push. Repeat 1 mg/kg every 5 mins until symptoms (rigidity/hypercarbia/fever) stop. Max 10 mg/kg. Neuroleptic Malignant Syndrome: **IV** 1-2.5 mg/kg, or **PO** 50-200 mg/day in divided doses (Off-label, but standard of care). Chronic Spasticity (Oral): Start **PO** 25 mg **OD**. Titrate up weekly. Max 400 mg/day (rarely used due to liver toxicity)." + }, + { + "label": "Best Uses", + "value": "Dantrolene is the only specific treatment for malignant hyperthermia and NMS, but causes hepatotoxicity requiring liver function monitoring and significant muscle weakness." + }, + { + "label": "Avoid / Cautions", + "value": "Active liver disease (for chronic oral use). NONE for IV emergency use. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Hepatic: Fatal symptomatic hepatitis (especially in females > 35 years taking oral doses > 300 mg/day for chronic spasticity). Neuromuscular: Profound, generalized muscle weakness (can impair respiratory muscles and swallowing). Gastrointestinal: Severe diarrhea, nausea." + }, + { + "label": "Key Interactions", + "value": "Calcium Channel Blockers (Verapamil, Diltiazem). Co-administration of IV Dantrolene with CCBs causes catastrophic cardiovascular collapse and hyperkalemia. NEVER mix." + }, + { + "label": "Monitoring", + "value": "For chronic oral use, baseline and frequent (monthly) **LFTs**. Stop immediately if transaminases rise. Check **U&E** (K+) and ABGs during acute crisis. Continuous ICU-level monitoring (Core temp, ETCO2, **HR**, **BP**) during MH crisis." + }, + { + "label": "Clinical Pearl", + "value": "Dantrolene powder is highly lipophilic and notoriously stubborn to dissolve in water. In an MH crisis, you need ~10 vials for an average adult. It takes multiple nurses furiously shaking 60mL syringes for minutes to prepare it. Newer formulations (Ryanodex) dissolve in 5mL instantly but are highly expensive." + } + ] + }, + { + "slug": "hydroxychloroquine", + "name": "Hydroxychloroquine", + "class": "Immunomodulator", + "subclass": "Antimalarial", + "category": "Musculoskeletal & Rheumatology", + "accent": "#475569", + "tag": "DMARD", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "40-50 DAYS", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Retinopathy", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Pregnancy", + "value": "SAFE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Antimalarial agent with potent immunomodulatory effects. The foundational, life-saving baseline drug for Systemic Lupus Erythematosus (SLE).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mg/day** (strictly weight-based: max 5 mg/kg of actual body weight).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Chronic use causes irreversible retinal toxicity. Annual optometry reviews are legally/clinically mandatory.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Hydroxychloroquine is a well-tolerated DMARD essential in SLE and useful in RA, but requires baseline and annual eye screening for irreversible retinal toxicity.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Ocular", + "val": "CRITICAL — 'Bulls-eye' maculopathy/retinopathy. Bilateral, irreversible blindness. Risk skyrockets after 5 years of use or cumulative doses > 1000g.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — **QTc** prolongation, rare cardiomyopathy.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, abdominal cramps (take with milk/food).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Hyperpigmentation (blue-black skin staining).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Rheumatoid Arthritis / SLE", + "val": "**PO** 200-400 mg daily with food. Keep long-term dose at or below 5 mg/kg/day actual body weight where possible to reduce retinopathy risk.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Plaquenil", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (200 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "SLE, Rheumatoid Arthritis, Malaria.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The only drug proven to improve overall survival and prevent organ damage in SLE. Mild DMARD for RA.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Pre-existing maculopathy.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — Continue when clinically indicated in SLE/autoimmune disease; pregnancy and breastfeeding decisions should be specialist-guided despite legacy Category D wording.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "info", + "severity": "info", + "note": "Hydroxychloroquine is commonly continued in pregnancy/breastfeeding for SLE/autoimmune disease under specialist guidance." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Other QTc prolonging drugs (e.g., Amiodarone, Macrolides).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "LOW — Antacids reduce absorption (separate by 4 hours).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Imaging / Consults", + "val": "MANDATORY — Baseline complete ophthalmology exam (OCT and visual fields) within 6 months of starting, then annually after 5 years of use.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **FBC** and **U&E**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Weight Limits", + "val": "Retinal toxicity is directly tied to overdosing. A 50 kg woman taking 400 mg/day is receiving 8 mg/kg/day (way over the 5 mg/kg limit) and will go blind. Calculate doses strictly on actual body weight.", + "tags": [] + }, + { + "key": "The Lupus Anchor", + "val": "In SLE, HCQ is the anchor. It prevents flares, prevents clots (antithrombotic), and reduces mortality. Never stop it without rheumatology advice.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Accumulates in lysosomes/endosomes, raising their pH. This impairs antigen processing and presentation by macrophages, halting the autoimmune cascade. Also blocks toll-like receptors.", + "tags": [] + }, + { + "key": "Onset", + "val": "Very slow. 2-6 months for maximum effect.", + "tags": [] + }, + { + "key": "Half-life", + "val": "40-50 DAYS. Concentrates heavily in melanin-rich tissues (like the retina).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: PLAQUENIL/hydroxychloroquine Australian PI/CMI and rheumatology guidance source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Antimalarial — Antimalarial agent with potent immunomodulatory effects." + }, + { + "label": "Route / Formulation", + "value": "Tablets (200 mg). (Plaquenil)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 200-400 mg **OD** (or divided **BD** with food). Max 5 mg/kg/day to prevent retinal damage." + }, + { + "label": "Best Uses", + "value": "Hydroxychloroquine is a well-tolerated DMARD essential in SLE and useful in RA, but requires baseline and annual eye screening for irreversible retinal toxicity." + }, + { + "label": "Avoid / Cautions", + "value": "Pre-existing maculopathy. **Pregnancy** Category D (historically), but modern rheumatology guidelines mandate continuing HCQ during pregnancy for SLE, as a flare is much more dangerous to the fetus." + }, + { + "label": "Key Risks", + "value": "Ocular: 'Bulls-eye' maculopathy/retinopathy. Bilateral, irreversible blindness. Risk skyrockets after 5 years of use or cumulative doses > 1000g. Cardiovascular: **QTc** prolongation, rare cardiomyopathy. Gastrointestinal: Nausea, abdominal cramps (take with milk/food). Dermatological: Hyperpigmentation (blue-black skin staining)." + }, + { + "label": "Key Interactions", + "value": "Other QTc prolonging drugs (e.g., Amiodarone, Macrolides). Antacids reduce absorption (separate by 4 hours)." + }, + { + "label": "Monitoring", + "value": "Baseline complete ophthalmology exam (OCT and visual fields) within 6 months of starting, then annually after 5 years of use. Routine **FBC** and **U&E**." + }, + { + "label": "Clinical Pearl", + "value": "Retinal toxicity is directly tied to overdosing. A 50 kg woman taking 400 mg/day is receiving 8 mg/kg/day (way over the 5 mg/kg limit) and will go blind. Calculate doses strictly on actual body weight." + } + ] + }, + { + "slug": "methotrexate", + "name": "Methotrexate", + "class": "Immunomodulator", + "subclass": "Antimetabolite", + "category": "Musculoskeletal & Rheumatology", + "accent": "#475569", + "tag": "DMARD", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "30 mg/week", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Freq", + "value": "ONCE WEEKLY", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Folic Acid", + "value": "MANDATORY", + "cls": "good", + "flag": "" + }, + { + "label": "Toxicity", + "value": "CRITICAL", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Folate antimetabolite. The absolute gold-standard, first-line Disease-Modifying Antirheumatic Drug (DMARD) for Rheumatoid Arthritis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **30 mg/WEEK** (For Rheumatology). Oncology doses are massively higher.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Low-dose methotrexate for inflammatory disease is ONCE WEEKLY. Daily dosing errors are a known fatal safety risk.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Methotrexate is the anchor DMARD for rheumatoid arthritis and psoriasis with proven long-term efficacy, but requires strict folic acid supplementation, regular blood monitoring, and is absolutely teratogenic.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Severe bone marrow suppression (pancytopenia, agranulocytosis) if overdosed or given daily.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "HIGH — Hepatotoxicity, fibrosis, cirrhosis (especially with chronic alcohol use).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Respiratory", + "val": "CRITICAL — Methotrexate pneumonitis (acute, potentially fatal hypersensitivity lung reaction).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe mucositis, mouth ulcers, nausea.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Rheumatoid Arthritis", + "val": "**PO** / **SC** 10-25 mg ONCE A WEEK. Usually taken on the same day every week (e.g., 'Methotrexate Mondays').", + "tags": [] + }, + { + "key": "Folic Acid Rescue", + "val": "**PO** 5 mg ONCE A WEEK (MANDATORY — taken 1 to 2 days AFTER the Methotrexate dose to reduce toxicity without blocking efficacy).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Renally cleared. Reduce or avoid depending on severity; do not use in severe renal impairment and review renal function before each dose.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Methotrexate can accumulate dangerously in severe renal impairment; review renal function before dosing." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Trexall, Methoblastin, Trexject (SC)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (2.5 mg, 10 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled syringes for **SC** injection (highly bioavailable, less GI upset).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Rheumatoid arthritis, severe psoriasis, Crohn's disease.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Ectopic pregnancy termination.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The anchor drug for RA. Often combined with biological agents.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal impairment, active liver disease, profound immunodeficiency, active severe infection.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — Contraindicated in pregnancy and breastfeeding. Use reliable contraception; pregnancy planning requires specialist washout advice.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "contraindication", + "severity": "danger", + "note": "Methotrexate is contraindicated in pregnancy and breastfeeding." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Trimethoprim (Bactrim). Completely blocks folate synthesis at a different step. Co-administration causes catastrophic bone marrow failure. NEVER combine.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — NSAIDs, Penicillins, PPIs (Reduce renal clearance of methotrexate, spiking toxicity).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Strict **FBC**, **LFTs**, and **U&E** checking every 1-2 months. Withhold drug if WBC drops or transaminases triple.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Warn patient to report any unexplained dry cough, breathlessness, or mouth ulcers instantly.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Daily Death Trap", + "val": "The most common fatal prescribing error in rheumatology is writing '10 mg Daily' instead of '10 mg Weekly'. Always double-check the script. Consider writing 'Methotrexate MONDAYS' to enforce the weekly concept.", + "tags": [] + }, + { + "key": "The Subcut Switch", + "val": "If a patient on oral Methotrexate hits 15-20 mg and stops absorbing it or develops severe nausea, switching to **SC** injections bypasses the gut, restores absorption, and cures the nausea.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Irreversibly binds and inhibits dihydrofolate reductase (DHFR). Deprives cells of active folate, halting DNA synthesis and inducing apoptosis in rapidly dividing inflammatory cells.", + "tags": [] + }, + { + "key": "Onset", + "val": "Weeks. Full effect takes 3-6 months.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-10 hours (Polyglutamated inside cells where it remains active for weeks).", + "tags": [] + } + ] + }, + { + "title": "Special Populations", + "type": "spec", + "rows": [ + { + "key": "Renal Impairment", + "val": "CRITICAL — Methotrexate is 85-90% renally excreted unchanged. If **eGFR** drops below 45, clearance is severely impaired and drug accumulates to toxic levels causing bone marrow failure, mucositis, and renal tubular necrosis. DO NOT use if **eGFR** < 30. Review every patient's renal function before each dose.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Elderly", + "val": "MANDATORY — Physiological decline in renal function with age means the standard once-weekly dose is often effectively overdosed in older patients. Use the lowest effective dose and monitor **eGFR** every 3 months.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CRITICAL — **Pregnancy** Category X. Potent abortifacient and teratogen (CNS, limb defects). Absolutely contraindicated. Requires reliable contraception 3 months before and during therapy in both males and females.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Lactation", + "val": "CRITICAL — Methotrexate is secreted in breast milk and accumulates in neonatal tissues. Absolutely contraindicated during breastfeeding.", + "tags": [], + "patient": { + "factors": ["lactation", "paediatric"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: METHOBLASTIN/methotrexate Australian PI/CMI and TGA weekly-dosing safety source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Antimetabolite — Folate antimetabolite." + }, + { + "label": "Route / Formulation", + "value": "Tablets (2.5 mg, 10 mg). (Trexall, Methoblastin, Trexject (SC))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** / **SC** 10-25 mg ONCE A WEEK. Usually taken on the same day every week (e.g., 'Methotrexate Mondays'). Max **30 mg/WEEK** (For Rheumatology). Oncology doses are massively higher." + }, + { + "label": "Key Indication Doses", + "value": "Rheumatoid Arthritis: **PO** / **SC** 10-25 mg ONCE A WEEK. Usually taken on the same day every week (e.g., 'Methotrexate Mondays'). Folic Acid Rescue: **PO** 5 mg ONCE A WEEK (MANDATORY — taken 1 to 2 days AFTER the Methotrexate dose to reduce toxicity without blocking efficacy). Renal Impairment: Reduce dose if **eGFR** < 60. Avoid if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Methotrexate is the anchor DMARD for rheumatoid arthritis and psoriasis with proven long-term efficacy, but requires strict folic acid supplementation, regular blood monitoring, and is absolutely teratogenic." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal impairment, active liver disease, profound immunodeficiency, active severe infection. **Pregnancy** Category D. Highly teratogenic (causes neural tube defects/abortion). Both men and women must use strict contraception for 6 months post-cessation." + }, + { + "label": "Key Risks", + "value": "Haematological: Severe bone marrow suppression (pancytopenia, agranulocytosis) if overdosed or given daily. Hepatic: Hepatotoxicity, fibrosis, cirrhosis (especially with chronic alcohol use). Respiratory: Methotrexate pneumonitis (acute, potentially fatal hypersensitivity lung reaction). Gastrointestinal: Severe mucositis, mouth ulcers, nausea." + }, + { + "label": "Key Interactions", + "value": "Trimethoprim (Bactrim). Completely blocks folate synthesis at a different step. Co-administration causes catastrophic bone marrow failure. NEVER combine. NSAIDs, Penicillins, PPIs (Reduce renal clearance of methotrexate, spiking toxicity)." + }, + { + "label": "Monitoring", + "value": "Strict **FBC**, **LFTs**, and **U&E** checking every 1-2 months. Withhold drug if WBC drops or transaminases triple. Warn patient to report any unexplained dry cough, breathlessness, or mouth ulcers instantly." + }, + { + "label": "Clinical Pearl", + "value": "The most common fatal prescribing error in rheumatology is writing '10 mg Daily' instead of '10 mg Weekly'. Always double-check the script. Consider writing 'Methotrexate MONDAYS' to enforce the weekly concept." + } + ] + }, + { + "slug": "orphenadrine", + "name": "Orphenadrine", + "class": "Muscle Relaxant", + "subclass": "Anticholinergic", + "category": "Musculoskeletal & Rheumatology", + "accent": "#d97706", + "tag": "ANTICHOLINERGIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "200 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "14 h", + "cls": "", + "flag": "" + }, + { + "label": "Abuse Risk", + "value": "EUPHORIA", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Anticholinergic", + "value": "SEVERE", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Centrally acting skeletal muscle relaxant with potent anticholinergic and antihistaminic properties. Used for acute, painful musculoskeletal spasms (e.g., lower back pain).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **200 mg/day** (Usually 100 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly euphoric with significant abuse potential. Causes severe anticholinergic toxicity (delirium, retention) in the elderly.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Orphenadrine is an anticholinergic muscle relaxant for acute musculoskeletal spasm, but has high anticholinergic burden making it dangerous in elderly and is cardiotoxic in overdose.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Euphoria, hallucinations, agitation, severe anticholinergic delirium. HIGH — Dizziness, blurred vision.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Tachycardia, palpitations, mild hypotension.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe dry mouth, constipation.", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "HIGH — Urinary retention (precipitates acute retention in men with BPH).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Muscle Spasm / Back Pain", + "val": "**PO** 100 mg **BD** (morning and evening).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Avoid completely if possible, or start at 50 mg/day. High risk of falls and confusion.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Norflex", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (100 mg - slow release). Do not crush.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Private script or hospital supply. Restricted due to abuse potential.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Symptomatic relief of acute, painful musculoskeletal conditions (e.g., acute torticollis, severe acute back spasm).", + "tags": ["TGA"] + }, + { + "key": "Off-Label", + "val": "Drug-induced parkinsonism/EPS.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Short-term adjunct therapy. Not for chronic use or spinal cord spasticity (use Baclofen instead).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Glaucoma, prostatic hypertrophy/urinary retention, pyloric or duodenal obstruction, achalasia/oesophageal spasm, myasthenia gravis, or tachycardia/cardiac decompensation.", + "tags": [] + }, + { + "key": "Elderly", + "val": "CRITICAL — Avoid in older adults or dementia where possible because anticholinergic delirium, falls, constipation, and urinary retention risk is high.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "caution", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Orphenadrine has high anticholinergic burden and can cause delirium, falls, constipation, and urinary retention in older adults." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive and severe anticholinergic toxicity when combined with TCAs (Amitriptyline), Antipsychotics, and Promethazine.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive CNS depression with Opioids and Benzos.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Assess bladder output and bowel opening. Monitor **HR** (tachycardia is a classic sign of toxicity).", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Euphoria Trap", + "val": "Because of its central NMDA/anticholinergic action, Orphenadrine produces a mild euphoria. Drug-seekers will frequently present to ED faking severe back spasms specifically requesting 'Norflex'. Be highly vigilant and restrict scripts to 3-5 days.", + "tags": [] + }, + { + "key": "Not for UMN Lesions", + "val": "Orphenadrine treats peripheral muscle spasms (like a pulled back muscle). It is completely useless for Upper Motor Neuron (UMN) spasticity like Multiple Sclerosis or cerebral palsy. Use Baclofen or Dantrolene for those.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Exact mechanism in muscle spasm is unknown, but acts centrally in the brainstem. Possesses strong antimuscarinic (anticholinergic), H1-antihistaminic, and NMDA-antagonist actions.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "14 hours. Extensively metabolised in the liver.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: NORFLEX/orphenadrine Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Anticholinergic — Centrally acting skeletal muscle relaxant with potent anticholinergic and antihistaminic properties." + }, + { + "label": "Route / Formulation", + "value": "Tablets (100 mg - slow release). Do not crush. (Norflex)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 100 mg **BD** (morning and evening). Max **200 mg/day** (Usually 100 mg BD)." + }, + { + "label": "Key Indication Doses", + "value": "Acute Muscle Spasm / Back Pain: **PO** 100 mg **BD** (morning and evening). Elderly / Frail: Avoid completely if possible, or start at 50 mg/day. High risk of falls and confusion." + }, + { + "label": "Best Uses", + "value": "Orphenadrine is an anticholinergic muscle relaxant for acute musculoskeletal spasm, but has high anticholinergic burden making it dangerous in elderly and is cardiotoxic in overdose." + }, + { + "label": "Avoid / Cautions", + "value": "Glaucoma, myasthenia gravis, mechanical GI obstruction, severe BPH with retention, tachyarrhythmias. **Pregnancy** Category B2." + }, + { + "label": "Key Risks", + "value": "Neurological: Euphoria, hallucinations, agitation, severe anticholinergic delirium. HIGH — Dizziness, blurred vision. Cardiovascular: Tachycardia, palpitations, mild hypotension. Gastrointestinal: Severe dry mouth, constipation. Genitourinary: Urinary retention (precipitates acute retention in men with BPH)." + }, + { + "label": "Key Interactions", + "value": "Additive and severe anticholinergic toxicity when combined with TCAs (Amitriptyline), Antipsychotics, and Promethazine. Additive CNS depression with Opioids and Benzos." + }, + { + "label": "Monitoring", + "value": "Assess bladder output and bowel opening. Monitor **HR** (tachycardia is a classic sign of toxicity). No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Because of its central NMDA/anticholinergic action, Orphenadrine produces a mild euphoria. Drug-seekers will frequently present to ED faking severe back spasms specifically requesting 'Norflex'. Be highly vigilant and restrict scripts to 3-5 days." + } + ] + }, + { + "slug": "probenecid", + "name": "Probenecid", + "class": "Gout", + "subclass": "Uricosuric", + "category": "Musculoskeletal & Rheumatology", + "accent": "#be123c", + "tag": "URICOSURIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "2000 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4-17 h", + "cls": "", + "flag": "" + }, + { + "label": "Fluids", + "value": "MANDATORY", + "cls": "good", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "INEFFECTIVE <50", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Uricosuric agent. Lowers serum uric acid by blocking its reabsorption in the kidneys, forcing the body to pee out the uric acid.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2000 mg/day** (given in divided doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Requires excellent baseline renal function to work. Massive risk of forming kidney stones if oral fluids are not forced.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Probenecid is a uricosuric agent for gout when allopurinol is not tolerated, but requires adequate renal function, high fluid intake, and is ineffective with eGFR < 30.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Renal", + "val": "CRITICAL — Uric acid nephrolithiasis (kidney stones), acute uric acid nephropathy.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, vomiting, anorexia.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Rash, hypersensitivity.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Chronic Gout", + "val": "Start **PO** 250 mg **BD** for 1 week. Titrate up by 500 mg every 4 weeks. Maintenance usually 500-1000 mg **BD**.", + "tags": [] + }, + { + "key": "Penicillin Adjuvant", + "val": "**PO** 500 mg **QID** (Used to boost penicillin blood levels for severe infections like neurosyphilis).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Probenecid AFT", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (500 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Gout prophylaxis (when allopurinol is contraindicated/failed).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Boosting beta-lactam antibiotic levels.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Second-line for chronic gout. Only useful for 'under-excreters' with healthy kidneys.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of uric acid kidney stones, acute gout flare, blood dyscrasias.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "HIGH — Ineffective or unsuitable with significant renal impairment; avoid in patients with uric acid stones and use only with high fluid intake and monitoring.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "caution", + "severity": "caution", + "match": { + "egfr": { + "lt": 50 + } + }, + "note": "Probenecid requires adequate renal function and high fluid intake; avoid with uric acid stone history." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Low-dose Aspirin antagonises the uricosuric effect of Probenecid. Do not use together.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Penicillins and Cephalosporins (massively increases their blood levels and half-life).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Methotrexate (reduces MTX clearance, spiking fatal toxicity).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Patient MUST drink 2-3 Litres of water daily to flush the uric acid out and prevent stone crystallization.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check renal function and monitor serum urate; use only if renal function is adequate for uricosuric therapy.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Stone Maker", + "val": "Because Probenecid dumps massive amounts of uric acid into the urine, the urine becomes highly saturated. If the patient gets dehydrated, uric acid stones will form instantly. Prescribe a urinary alkaliser (e.g., Ural) concurrently to keep the uric acid dissolved.", + "tags": [] + }, + { + "key": "The Syphilis Hack", + "val": "Infectious disease doctors use Probenecid intentionally to block the kidneys from peeing out penicillin. This allows them to achieve massive, sustained CNS penicillin levels required to cure neurosyphilis.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitively inhibits the URAT1 transporter in the proximal renal tubule. Blocks reabsorption of uric acid, causing massive uricosuria. Also blocks tubular secretion of penicillins.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "4-17 hours (Dose-dependent).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: PROBENECID AFT Australian CMI and gout guidance source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Uricosuric — Uricosuric agent." + }, + { + "label": "Route / Formulation", + "value": "Tablets (500 mg). (Probenecid AFT)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 250 mg **BD** for 1 week. Titrate up by 500 mg every 4 weeks. Maintenance usually 500-1000 mg **BD**. Max **2000 mg/day** (given in divided doses)." + }, + { + "label": "Key Indication Doses", + "value": "Chronic Gout: Start **PO** 250 mg **BD** for 1 week. Titrate up by 500 mg every 4 weeks. Maintenance usually 500-1000 mg **BD**. Penicillin Adjuvant: **PO** 500 mg **QID** (Used to boost penicillin blood levels for severe infections like neurosyphilis)." + }, + { + "label": "Best Uses", + "value": "Probenecid is a uricosuric agent for gout when allopurinol is not tolerated, but requires adequate renal function, high fluid intake, and is ineffective with eGFR < 30." + }, + { + "label": "Avoid / Cautions", + "value": "History of uric acid kidney stones, acute gout flare, blood dyscrasias. **Pregnancy** Category B2." + }, + { + "label": "Key Risks", + "value": "Renal: Uric acid nephrolithiasis (kidney stones), acute uric acid nephropathy. Gastrointestinal: Nausea, vomiting, anorexia. Dermatological: Rash, hypersensitivity." + }, + { + "label": "Key Interactions", + "value": "Low-dose Aspirin antagonises the uricosuric effect of Probenecid. Do not use together. Penicillins and Cephalosporins (massively increases their blood levels and half-life). Methotrexate (reduces MTX clearance, spiking fatal toxicity)." + }, + { + "label": "Monitoring", + "value": "Patient MUST drink 2-3 Litres of water daily to flush the uric acid out and prevent stone crystallization. Check **eGFR** (must be > 50). Monitor serum urate." + }, + { + "label": "Clinical Pearl", + "value": "Because Probenecid dumps massive amounts of uric acid into the urine, the urine becomes highly saturated. If the patient gets dehydrated, uric acid stones will form instantly. Prescribe a urinary alkaliser (e.g., Ural) concurrently to keep the uric acid dissolved." + } + ] + }, + { + "slug": "armodafinil", + "name": "Armodafinil", + "class": "Wake-promoting", + "subclass": "Dopamine Reuptake Inhibitor", + "category": "Neurology - ADHD & Cognition", + "accent": "#d97706", + "tag": "NOT S8", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "250 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "15 h", + "cls": "", + "flag": "" + }, + { + "label": "OCP Failure", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "SJS/TEN", + "value": "RARE BUT FATAL", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The purified, long-acting R-enantiomer of Modafinil. A highly potent wakefulness-promoting agent. Keeps the patient alert without the severe cardiovascular rush or addiction potential of amphetamines.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **250 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Induces CYP enzymes, rendering the oral contraceptive pill (OCP) completely useless. Can trigger life-threatening skin detachments (SJS/TEN).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Armodafinil is a wakefulness-promoting agent for narcolepsy and shift work disorder, but can reduce hormonal contraceptive efficacy and may be abused for cognitive enhancement.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Dermatological", + "val": "CRITICAL — Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), DRESS syndrome. Highest risk is in the first 1-5 weeks of therapy.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Headache (extremely common, >15%), severe insomnia, anxiety, agitation.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Mild tachycardia, palpitations, hypertension.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Narcolepsy / Sleep Apnea Fatigue", + "val": "**PO** 150-250 mg **OD** in the morning.", + "tags": [] + }, + { + "key": "Shift Work Sleep Disorder", + "val": "**PO** 150 mg **OD** taken exactly 1 hour before the start of the night shift.", + "tags": [] + }, + { + "key": "Severe Hepatic Impairment", + "val": "MANDATORY — Halve the dose.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nuvigil", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (50, 150, 250 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for narcolepsy/OSA. Private script for shift workers. Unlike Dexamphetamine, it is NOT an S8 controlled drug (it is S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Narcolepsy, excessive sleepiness in Obstructive Sleep Apnea (OSA), Shift Work Sleep Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Severe fatigue in multiple sclerosis, depression-associated fatigue.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The gold standard for keeping shift-workers awake and functional without turning them into amphetamine addicts.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of left ventricular hypertrophy, mitral valve prolapse, or ischemic ECG changes with prior CNS stimulants.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Must be ceased 2 months before planned conception.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Armodafinil pregnancy row remains a source-backed high-risk/contraindication prompt." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — Strong inducer of **CYP3A4**. It rapidly destroys the estrogen/progesterone in the Combined Oral Contraceptive Pill. Women MUST use alternative non-hormonal contraception (Copper IUD) while on the drug and for 1 month after stopping.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Inhibits CYP2C19 (Spikes levels of Diazepam, Phenytoin, Omeprazole).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn the patient: 'If you develop ANY skin rash, mouth ulcers, or fever, stop the drug immediately and go to the Emergency Department.'", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor **BP** and **HR**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Modafinil vs Armodafinil", + "val": "Standard Modafinil (Modavigil) is a 50:50 mix of the R and S enantiomers. The S-enantiomer wears off in 4 hours, causing an afternoon 'crash'. Armodafinil (Nuvigil) contains ONLY the R-enantiomer, providing a smooth, flat, 15-hour wakefulness curve with no afternoon crash.", + "tags": [] + }, + { + "key": "The Headache Fix", + "val": "The intense headaches caused by Armodafinil are often related to dehydration (the drug acts as a mild diuretic and suppresses the thirst mechanism) or muscular jaw clenching. Forcing hydration and taking paracetamol usually resolves it.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Atypical dopamine reuptake inhibitor. Binds to the dopamine transporter (DAT) but in a different conformation to cocaine/amphetamines, producing sustained wakefulness without euphoria or rapid tolerance. Also activates hypothalamic orexin/orexin pathways.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-15 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "15 hours (The R-enantiomer lasts significantly longer than the S-enantiomer found in standard Modafinil).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - NUVIGIL ARTG/PI, TGA safety update, and PBS search checked 2026-05-10 for ADHD/stimulant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Dopamine Reuptake Inhibitor — The purified, long-acting R-enantiomer of Modafinil." + }, + { + "label": "Route / Formulation", + "value": "Tablets (50, 150, 250 mg). (Nuvigil)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 150-250 mg **OD** in the morning. Max **250 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Narcolepsy / Sleep Apnea Fatigue: **PO** 150-250 mg **OD** in the morning. Shift Work Sleep Disorder: **PO** 150 mg **OD** taken exactly 1 hour before the start of the night shift. Severe Hepatic Impairment: Halve the dose." + }, + { + "label": "Best Uses", + "value": "Armodafinil is a wakefulness-promoting agent for narcolepsy and shift work disorder, but can reduce hormonal contraceptive efficacy and may be abused for cognitive enhancement." + }, + { + "label": "Avoid / Cautions", + "value": "History of left ventricular hypertrophy, mitral valve prolapse, or ischemic ECG changes with prior CNS stimulants. **Pregnancy** Category D. Must be ceased 2 months before planned conception." + }, + { + "label": "Key Risks", + "value": "Dermatological: Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), DRESS syndrome. Highest risk is in the first 1-5 weeks of therapy. Neurological: Headache (extremely common, >15%), severe insomnia, anxiety, agitation. Cardiovascular: Mild tachycardia, palpitations, hypertension." + }, + { + "label": "Key Interactions", + "value": "Strong inducer of **CYP3A4**. It rapidly destroys the estrogen/progesterone in the Combined Oral Contraceptive Pill. Women MUST use alternative non-hormonal contraception (Copper IUD) while on the drug and for 1 month after stopping. Inhibits CYP2C19 (Spikes levels of Diazepam, Phenytoin, Omeprazole)." + }, + { + "label": "Monitoring", + "value": "Warn the patient: 'If you develop ANY skin rash, mouth ulcers, or fever, stop the drug immediately and go to the Emergency Department.'. Monitor **BP** and **HR**." + }, + { + "label": "Clinical Pearl", + "value": "Standard Modafinil (Modavigil) is a 50:50 mix of the R and S enantiomers. The S-enantiomer wears off in 4 hours, causing an afternoon 'crash'. Armodafinil (Nuvigil) contains ONLY the R-enantiomer, providing a smooth, flat, 15-hour wakefulness curve with no afternoon crash." + } + ] + }, + { + "slug": "donepezil", + "name": "Donepezil", + "class": "Neurology", + "subclass": "AChE Inhibitor", + "category": "Neurology - Anti-Parkinson & Cognitive", + "accent": "#475569", + "tag": "COGNITIVE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "70 h", + "cls": "", + "flag": "" + }, + { + "label": "Bradycardia", + "value": "RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Vivid Dreams", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Central acetylcholinesterase (AChE) inhibitor. Increases acetylcholine in the brain to delay cognitive decline in Alzheimer's disease.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Enhancing acetylcholine systemically slows the heart and stimulates the gut. High risk of bradycardia, syncope, and severe diarrhea.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Donepezil is the first-line cholinesterase inhibitor for mild-moderate Alzheimer's disease, but provides only modest symptomatic benefit and causes GI side effects and bradycardia.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Bradycardia, AV block, syncope/falls (due to increased vagal tone).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, vomiting, diarrhea, anorexia/weight loss.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Insomnia, intense vivid dreams/nightmares, muscle cramps.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Alzheimer's Disease", + "val": "Start **PO** 5 mg **NOCTE**; after at least 1 month, increase to **10 mg NOCTE** if tolerated. Move to morning dosing if vivid dreams or insomnia occur.", + "tags": [] + }, + { + "key": "Vivid Dreams", + "val": "If patient suffers horrific nightmares, switch the dose from NOCTE to the morning (**mane**).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Aricept", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg, 10 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Must have confirmed Alzheimer's diagnosis by a specialist/geriatrician.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Mild, moderate, and severe Alzheimer's dementia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Does not cure or stop the disease, but temporarily improves cognition and daily function for 6-12 months.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Hypersensitivity. Use specialist caution or avoid initiation without review in sick sinus syndrome, unpaced conduction disease, bradycardia/syncope risk, active peptic ulcer disease or NSAID use, seizure history, and severe asthma/COPD.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "CAUTION — Severe asthma/COPD (cholinergic stimulation can trigger bronchospasm).", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Anticholinergics (e.g., Oxybutynin, Amitriptyline, Promethazine). These drugs directly cancel each other out. Prescribing both is irrational and guarantees clinical failure.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers, Amiodarone (additive bradycardia/syncope).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **HR**. Assess weight and appetite regularly in the frail elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Cardiac", + "val": "MANDATORY — Check pulse and consider baseline ECG where bradycardia, syncope, conduction disease, beta-blocker/digoxin/amiodarone use, or unexplained falls are present.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Nightmare Switch", + "val": "Donepezil increases REM sleep density. Prescribing it at night causes incredibly vivid, often terrifying dreams in dementia patients. Moving the dose to breakfast cures the nightmares immediately.", + "tags": [] + }, + { + "key": "The Urinary Trap", + "val": "A classic prescribing cascade: Donepezil causes urinary incontinence (cholinergic overactivity). The doctor prescribes Oxybutynin (anticholinergic) to fix the incontinence. The Oxybutynin crosses the BBB and completely destroys the patient's remaining memory, causing severe delirium.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Reversibly and non-competitively inhibits acetylcholinesterase centrally, preventing the breakdown of acetylcholine, enhancing cholinergic transmission in the cerebral cortex.", + "tags": [] + }, + { + "key": "Onset", + "val": "Weeks for cognitive benefit. Side effects are immediate.", + "tags": [] + }, + { + "key": "Half-life", + "val": "70 hours (Highly protein bound, steady state takes 3 weeks). Metabolised by CYP3A4/2D6.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: ARICEPT donepezil Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "AChE Inhibitor — Central acetylcholinesterase (AChE) inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg, 10 mg). (Aricept)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 5 mg **NOCTE**. Assess tolerance for 4-6 weeks. Increase to Max **10 mg NOCTE** if tolerated." + }, + { + "label": "Key Indication Doses", + "value": "Alzheimer's Disease: Start **PO** 5 mg **NOCTE**. Assess tolerance for 4-6 weeks. Increase to Max **10 mg NOCTE** if tolerated. Vivid Dreams: If patient suffers horrific nightmares, switch the dose from NOCTE to the morning (**mane**)." + }, + { + "label": "Best Uses", + "value": "Donepezil is the first-line cholinesterase inhibitor for mild-moderate Alzheimer's disease, but provides only modest symptomatic benefit and causes GI side effects and bradycardia." + }, + { + "label": "Avoid / Cautions", + "value": "Sick sinus syndrome, un-paced heart block, active peptic ulcer disease." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Bradycardia, AV block, syncope/falls (due to increased vagal tone). Gastrointestinal: Nausea, vomiting, diarrhea, anorexia/weight loss. Neurological: Insomnia, intense vivid dreams/nightmares, muscle cramps." + }, + { + "label": "Key Interactions", + "value": "Anticholinergics (e.g., Oxybutynin, Amitriptyline, Promethazine). These drugs directly cancel each other out. Prescribing both is irrational and guarantees clinical failure. Beta-blockers, Amiodarone (additive bradycardia/syncope)." + }, + { + "label": "Monitoring", + "value": "Monitor **HR**. Assess weight and appetite regularly in the frail elderly. Baseline **ECG** to check for heart block prior to initiation." + }, + { + "label": "Clinical Pearl", + "value": "Donepezil increases REM sleep density. Prescribing it at night causes incredibly vivid, often terrifying dreams in dementia patients. Moving the dose to breakfast cures the nightmares immediately." + } + ] + }, + { + "slug": "levodopa-benserazide", + "name": "Levodopa/Benserazide", + "class": "Neurology", + "subclass": "Dopamine Precursor", + "category": "Neurology - Anti-Parkinson & Cognitive", + "accent": "#475569", + "tag": "ANTI-PARKINSON", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1000+ mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1.5 h", + "cls": "", + "flag": "" + }, + { + "label": "Withdrawal", + "value": "NMS RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Dyskinesia", + "value": "CHRONIC RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The gold-standard dopamine replacement therapy for Parkinson's Disease. Levodopa crosses the BBB, while Benserazide stops it from breaking down in the body, preventing severe nausea.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated strictly to effect. Standard max is ~1000 mg/day of Levodopa component.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Doses MUST be given exactly on time (e.g., 0800, 1200, 1600). A 30-minute delay leaves the patient frozen and unable to move or swallow.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Levodopa/Benserazide is the most effective treatment for Parkinson's motor symptoms, but long-term use inevitably causes motor fluctuations (wearing-off, dyskinesias) requiring careful dose timing.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Abrupt withdrawal can trigger parkinsonism-hyperpyrexia/NMS-like syndrome. Chronic use can cause dyskinesias and wearing-off/on-off fluctuations; adjust with specialist input.", + "tags": [] + }, + { + "key": "Psychiatric", + "val": "HIGH — Visual hallucinations, psychosis, severe impulse control disorders (gambling/hypersexuality), confusion.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Orthostatic hypotension, syncope.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea/Vomiting (mitigated by the benserazide).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Parkinson's Disease", + "val": "Start **PO** 50/12.5 mg **BD** or **TDS**. Gradually titrate up over weeks. Maintenance often 100/25 mg **TDS** to **QID**.", + "tags": [] + }, + { + "key": "Restless Legs Syndrome", + "val": "**PO** 50/12.5 mg **NOCTE** (Off-label).", + "tags": [] + }, + { + "key": "Timing", + "val": "MANDATORY — Take doses consistently relative to meals. Protein can reduce levodopa effect; if wearing-off occurs, separate from high-protein meals, but balance this against nausea and adherence.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Madopar (Levodopa/Benserazide), Sinemet (Levodopa/Carbidopa)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets (50/12.5 mg, 100/25 mg, 200/50 mg). Dispersible tablets (Madopar Rapid). Controlled Release (HBS).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Parkinson's disease (PD).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The most effective drug for treating the bradykinesia and rigidity of PD.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Non-selective MAOIs or combined MAO-A plus MAO-B inhibition, narrow-angle glaucoma, suspicious undiagnosed skin lesions or melanoma history, and decompensated endocrine, renal, hepatic, or cardiac disease without specialist review.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Existing row flags decompensated renal/hepatic disease without specialist review; cardiac, endocrine and melanoma risks remain in row text." + } + }, + { + "key": "Psychiatric", + "val": "CAUTION — Exacerbates underlying psychosis/schizophrenia.", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Antipsychotics (Haloperidol, Metoclopramide) are D2 antagonists. They directly block Levodopa from working, instantly paralyzing the Parkinson's patient. If an antiemetic is needed, use Domperidone or Ondansetron. If an antipsychotic is needed, use Quetiapine.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Give exactly on time; monitor orthostatic BP, hallucinations/psychosis, impulse-control disorders, dyskinesia, and wearing-off. Do not abruptly stop.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Protein Wall", + "val": "Amino acids from dietary protein compete with Levodopa for the exact same transporter across the gut wall and the blood-brain barrier. If taken with a steak dinner, absorption drops to near zero. Must be taken on an empty stomach.", + "tags": [] + }, + { + "key": "The Dispersible Rescue", + "val": "If a PD patient wakes up completely 'frozen' (off-state) and cannot swallow a tablet, Madopar Rapid (dispersible) dissolves in a teaspoon of water and hits the system in 15 minutes, 'thawing' the patient out.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Levodopa actively crosses the BBB and is decarboxylated into Dopamine. Benserazide (a peripheral decarboxylase inhibitor) cannot cross the BBB; it stops Levodopa turning into Dopamine in the gut/blood, preventing severe systemic nausea and tachycardia.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins (Faster with dispersible).", + "tags": [] + }, + { + "key": "Duration", + "val": "2-4 h (Very short, causing 'wearing off' fluctuations in advanced PD).", + "tags": [] + }, + { + "key": "Half-life", + "val": "1.5 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: MADOPAR levodopa/benserazide Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Dopamine Precursor — The gold-standard dopamine replacement therapy for Parkinson's Disease." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets (50/12.5 mg, 100/25 mg, 200/50 mg). Dispersible tablets (Madopar Rapid). Controlled Release (HBS). (Madopar (Levodopa/Benserazide), Sinemet (Levodopa/Carbidopa))" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 50/12.5 mg **BD** or **TDS**. Gradually titrate up over weeks. Maintenance often 100/25 mg **TDS** to **QID**. Titrated strictly to effect. Standard max is ~1000 mg/day of Levodopa component." + }, + { + "label": "Key Indication Doses", + "value": "Parkinson's Disease: Start **PO** 50/12.5 mg **BD** or **TDS**. Gradually titrate up over weeks. Maintenance often 100/25 mg **TDS** to **QID**. Restless Legs Syndrome: **PO** 50/12.5 mg **NOCTE** (Off-label). Timing: Take 30-60 mins BEFORE meals to avoid protein blocking absorption." + }, + { + "label": "Best Uses", + "value": "Levodopa/Benserazide is the most effective treatment for Parkinson's motor symptoms, but long-term use inevitably causes motor fluctuations (wearing-off, dyskinesias) requiring careful dose timing." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of non-selective MAOIs, narrow-angle glaucoma." + }, + { + "label": "Key Risks", + "value": "Neurological: Parkinsonism-Hyperpyrexia Syndrome (similar to NMS) if abruptly withdrawn. HIGH — Dyskinesias (writhing, chorea-like movements) with chronic use. 'On-Off' fluctuations. Psychiatric: Visual hallucinations, psychosis, severe impulse control disorders (gambling/hypersexuality), confusion. Cardiovascular: Orthostatic hypotension, syncope. Gastrointestinal: Nausea/Vomiting (mitigated by the benserazide)." + }, + { + "label": "Key Interactions", + "value": "Antipsychotics (Haloperidol, Metoclopramide) are D2 antagonists. They directly block Levodopa from working, instantly paralyzing the Parkinson's patient. If an antiemetic is needed, use Domperidone or Ondansetron. If an antipsychotic is needed, use Quetiapine." + }, + { + "label": "Monitoring", + "value": "Strict adherence to medication timings. Monitor for orthostatic **BP** drops and hallucinations. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Amino acids from dietary protein compete with Levodopa for the exact same transporter across the gut wall and the blood-brain barrier. If taken with a steak dinner, absorption drops to near zero. Must be taken on an empty stomach." + } + ] + }, + { + "slug": "memantine", + "name": "Memantine", + "class": "Neurology", + "subclass": "NMDA Receptor Antagonist", + "category": "Neurology - Anti-Parkinson & Cognitive", + "accent": "#475569", + "tag": "COGNITIVE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "60-100 h", + "cls": "", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "MANDATORY", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Agitation", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "NMDA receptor antagonist. Protects neurons from glutamate excitotoxicity. Used for moderate-to-severe Alzheimer's, often layered on top of Donepezil.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Unlike Donepezil, it relies entirely on the kidneys for clearance and does not cause bradycardia or GI upset.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Memantine is the NMDA antagonist for moderate-severe Alzheimer's disease (alone or with donepezil), but provides only modest benefit and can cause dizziness, headache, and confusion.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "MODERATE — Dizziness, confusion, headache. Somnolence or paradoxical agitation.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Hypertension.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Constipation (Notice it causes constipation, whereas Donepezil causes diarrhea).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Alzheimer's Disease", + "val": "Week 1: **PO** 5 mg **OD**. Week 2: 10 mg. Week 3: 15 mg. Week 4: 20 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Dose by renal function. Severe renal impairment (CrCl/eGFR 5-29 mL/min): max **10 mg/day**. Mild-moderate impairment generally does not require reduction but monitor tolerability.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Memantine requires dose limitation in severe renal impairment." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Ebixa", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg, 20 mg). Oral liquid/drops.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Moderate to severe Alzheimer's disease.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Used when Alzheimer's progresses beyond the mild stage. Often used in combination with Donepezil for additive benefits.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CAUTION — Severe renal impairment is not an absolute contraindication by itself, but dose reduction is mandatory; avoid if renal function cannot be monitored or neurotoxicity emerges.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Memantine requires dose limitation and monitoring in severe renal impairment." + } + }, + { + "key": "Neurological", + "val": "CAUTION — History of seizures.", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Other NMDA antagonists (Amantadine, Ketamine, Dextromethorphan). Avoid combination due to risk of pharmacotoxic psychosis.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "LOW — Very clean metabolic profile (no CYP interactions).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check baseline renal function and repeat if renal status changes, intercurrent illness occurs, or confusion/agitation worsens during titration.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor for worsening confusion or agitation during the initial 4-week titration phase.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Synergy", + "val": "Because Donepezil and Memantine have completely different mechanisms (boosting ACh vs blocking Glutamate) and opposite side effects (diarrhea vs constipation), combining them in severe Alzheimer's is highly logical and often cancels out the GI side effects.", + "tags": [] + }, + { + "key": "The Urine Alkalinity Trap", + "val": "If the patient's urine becomes highly alkaline (e.g., severe UTI with Proteus, or taking lots of Ural/bicarbonate), the kidneys stop excreting Memantine, leading to an 80% drop in clearance and severe toxicity.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Uncompetitive NMDA-receptor antagonist. Blocks the constant, low-level 'noise' of pathological glutamate signaling (which destroys neurons via calcium overload), while allowing the high-level bursts of glutamate needed for actual memory formation to pass through.", + "tags": [] + }, + { + "key": "Onset", + "val": "Weeks to months.", + "tags": [] + }, + { + "key": "Half-life", + "val": "60-100 hours. Predominantly excreted unchanged in the urine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: EBIXA memantine Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "NMDA Receptor Antagonist — NMDA receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg, 20 mg). Oral liquid/drops. (Ebixa)" + }, + { + "label": "Usual Dose & Max", + "value": "Week 1: **PO** 5 mg **OD**. Week 2: 10 mg. Week 3: 15 mg. Week 4: 20 mg **OD**. Max **20 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Alzheimer's Disease: Week 1: **PO** 5 mg **OD**. Week 2: 10 mg. Week 3: 15 mg. Week 4: 20 mg **OD**. Renal Impairment: If **eGFR** 30-49, Max 10 mg/day. If **eGFR** < 30, avoid or strictly limit to 5 mg/day." + }, + { + "label": "Best Uses", + "value": "Memantine is the NMDA antagonist for moderate-severe Alzheimer's disease (alone or with donepezil), but provides only modest benefit and can cause dizziness, headache, and confusion." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal failure (accumulation causes intense neurotoxicity)." + }, + { + "label": "Key Risks", + "value": "Neurological: Dizziness, confusion, headache. Somnolence or paradoxical agitation. Cardiovascular: Hypertension. Gastrointestinal: Constipation (Notice it causes constipation, whereas Donepezil causes diarrhea)." + }, + { + "label": "Key Interactions", + "value": "Other NMDA antagonists (Amantadine, Ketamine, Dextromethorphan). Avoid combination due to risk of pharmacotoxic psychosis. Very clean metabolic profile (no CYP interactions)." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **U&E** and **eGFR** to guide safe dosing limits. Monitor for worsening confusion or agitation during the initial 4-week titration phase." + }, + { + "label": "Clinical Pearl", + "value": "Because Donepezil and Memantine have completely different mechanisms (boosting ACh vs blocking Glutamate) and opposite side effects (diarrhea vs constipation), combining them in severe Alzheimer's is highly logical and often cancels out the GI side effects." + } + ] + }, + { + "slug": "carbamazepine", + "name": "Carbamazepine", + "class": "Mood Stabiliser", + "subclass": "Dibenzazepine", + "category": "Neurology - Anticonvulsants", + "accent": "#0891b2", + "tag": "MOOD STAB", + "schedule": "S4", + "stats": [ + { + "label": "Target Range", + "value": "17–42 umol/L", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "15 h (Auto-inducer)", + "cls": "", + "flag": "" + }, + { + "label": "CYP Inducer", + "value": "POTENT", + "cls": "hi", + "flag": "warn" + }, + { + "label": "SJS/TEN", + "value": "HLA-B*1502", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Broad-spectrum anticonvulsant. A notoriously difficult drug to manage due to auto-induction (it speeds up its own liver metabolism over time) and catastrophic drug interactions.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2000 mg/day** (Titrated via TDM).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "One of the most potent CYP450 inducers in human medicine. It will completely obliterate the blood levels of Oral Contraceptives, DOACs, and Antipsychotics.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Carbamazepine is an anticonvulsant and mood stabiliser for focal seizures and trigeminal neuralgia, but is a potent CYP inducer with extensive drug interactions and requires HLA-B*15:02 testing in at-risk populations.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Dermatological", + "val": "CRITICAL — Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN). Massive risk in patients of Asian descent carrying the HLA-B*1502 allele.", + "tags": [] + }, + { + "key": "Haematological", + "val": "CRITICAL — Agranulocytosis, aplastic anemia (Rare but fatal).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Hyponatremia (SIADH), though less common than with Oxcarbazepine.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Dizziness, ataxia, diplopia (double vision).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Epilepsy", + "val": "Start **PO** 100-200 mg **BD**. Titrate slowly to target 400-1000 mg **BD** (Requires Controlled Release formulation for BD dosing).", + "tags": [] + }, + { + "key": "Trigeminal Neuralgia", + "val": "**PO** 100 mg **BD**. Titrate to response (Often provides miraculous pain relief).", + "tags": [] + }, + { + "key": "Bipolar Mania", + "val": "**PO** 200-400 mg/day in divided doses.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Tegretol, Tegretol CR, Teril", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets IR (100, 200 mg). CR Tablets (200, 400 mg). Oral liquid.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Focal (partial) seizures, generalized tonic-clonic seizures, trigeminal neuralgia, bipolar disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Gold standard for Trigeminal Neuralgia. Increasingly avoided for epilepsy due to newer, safer drugs (Levetiracetam) lacking enzyme interactions.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Prior bone marrow depression, concurrent MAOIs, AV heart block.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D (Spina bifida, craniofacial defects).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Carbamazepine pregnancy row remains a source-backed high-risk/contraindication prompt." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Massively induces CYP3A4, CYP1A2, and CYP2C9. Destroys efficacy of DOACs (Apixaban/Rivaroxaban), Warfarin, Oral Contraceptives, Clozapine, Quetiapine, and Macrolides. A nightmare for polypharmacy.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Valproate pushes Carbamazepine off proteins and inhibits its breakdown, causing a massive spike in the toxic active metabolite (carbamazepine-10,11-epoxide).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **TDM** (Target: 17-42 umol/L). Must check **FBC** (for marrow suppression), **U&E** (sodium), and **LFTs** at baseline and periodically.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Stop the drug instantly and go to ED if ANY skin rash, mouth ulcers, or severe sore throat develops.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Auto-Induction Trap", + "val": "You prescribe a patient 200mg BD. In week 2, their seizures stop and their blood levels are perfect. In week 4, the seizures return. The drug has forced the liver to build more enzymes, digesting the drug twice as fast. You MUST re-check levels at 4 weeks and increase the dose.", + "tags": [] + }, + { + "key": "The Neuralgia Nuke", + "val": "Trigeminal Neuralgia (the 'suicide disease') causes agonizing, electric-shock face pain. Standard opioids are useless. Carbamazepine essentially 'turns off' the trigeminal nerve, providing profound relief.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to voltage-gated sodium channels in their inactive state, slowing their recovery and preventing high-frequency repetitive firing in neurons.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Initially 30-40 hours. After 3-4 weeks, the drug 'auto-induces' the liver, dropping its own half-life to 10-15 hours. Dose must often be increased at week 4 to maintain levels.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TEGRETOL ARTG/PI and PBS search checked 2026-05-10 for mood-stabiliser/anticonvulsant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Dibenzazepine — Broad-spectrum anticonvulsant." + }, + { + "label": "Route / Formulation", + "value": "Tablets IR (100, 200 mg). CR Tablets (200, 400 mg). Oral liquid. (Tegretol, Tegretol CR, Teril)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 100-200 mg **BD**. Titrate slowly to target 400-1000 mg **BD** (Requires Controlled Release formulation for BD dosing). Max **2000 mg/day** (Titrated via TDM)." + }, + { + "label": "Key Indication Doses", + "value": "Epilepsy: Start **PO** 100-200 mg **BD**. Titrate slowly to target 400-1000 mg **BD** (Requires Controlled Release formulation for BD dosing). Trigeminal Neuralgia: **PO** 100 mg **BD**. Titrate to response (Often provides miraculous pain relief). Bipolar Mania: **PO** 200-400 mg/day in divided doses." + }, + { + "label": "Best Uses", + "value": "Carbamazepine is an anticonvulsant and mood stabiliser for focal seizures and trigeminal neuralgia, but is a potent CYP inducer with extensive drug interactions and requires HLA-B*15:02 testing in at-risk populations." + }, + { + "label": "Avoid / Cautions", + "value": "Prior bone marrow depression, concurrent MAOIs, AV heart block. **Pregnancy** Category D (Spina bifida, craniofacial defects)." + }, + { + "label": "Key Risks", + "value": "Dermatological: Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN). Massive risk in patients of Asian descent carrying the HLA-B*1502 allele. Haematological: Agranulocytosis, aplastic anemia (Rare but fatal). Metabolic: Hyponatremia (SIADH), though less common than with Oxcarbazepine. Neurological: Dizziness, ataxia, diplopia (double vision)." + }, + { + "label": "Key Interactions", + "value": "Massively induces CYP3A4, CYP1A2, and CYP2C9. Destroys efficacy of DOACs (Apixaban/Rivaroxaban), Warfarin, Oral Contraceptives, Clozapine, Quetiapine, and Macrolides. A nightmare for polypharmacy. Valproate pushes Carbamazepine off proteins and inhibits its breakdown, causing a massive spike in the toxic active metabolite (carbamazepine-10,11-epoxide)." + }, + { + "label": "Monitoring", + "value": "**TDM** (Target: 17-42 umol/L). Must check **FBC** (for marrow suppression), **U&E** (sodium), and **LFTs** at baseline and periodically. Stop the drug instantly and go to ED if ANY skin rash, mouth ulcers, or severe sore throat develops." + }, + { + "label": "Clinical Pearl", + "value": "You prescribe a patient 200mg BD. In week 2, their seizures stop and their blood levels are perfect. In week 4, the seizures return. The drug has forced the liver to build more enzymes, digesting the drug twice as fast. You MUST re-check levels at 4 weeks and increase the dose." + } + ] + }, + { + "slug": "gabapentin", + "name": "Gabapentin", + "class": "Anxiolytic", + "subclass": "Alpha-2-delta ligand", + "category": "Neurology - Anticonvulsants", + "accent": "#0891b2", + "tag": "GABAPENTINOID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "3600 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5-7 h", + "cls": "", + "flag": "" + }, + { + "label": "Bioavailability", + "value": "INVERSE DOSE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Gabapentinoid. Designed for epilepsy but used almost exclusively today for neuropathic pain. Highly unique pharmacokinetics: the more you swallow, the less you absorb.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **3600 mg/day** (e.g., 1200 mg TDS).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Synergistic respiratory depression when mixed with Opioids. Heavily renally cleared.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Gabapentin is an anticonvulsant widely used for neuropathic pain, but has limited evidence for many off-label uses and increasing Schedule 8 restrictions due to misuse and dependence potential.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Somnolence, dizziness, ataxia, fatigue (Extremely common, requires glacial titration).", + "tags": [] + }, + { + "key": "Respiratory", + "val": "CRITICAL — Severe respiratory depression (Only a major risk if combined with opioids/benzos or in unadjusted renal failure).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Weight gain, peripheral edema.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Neuropathic Pain", + "val": "Day 1: **PO** 300 mg **OD**. Day 2: 300 mg **BD**. Day 3: 300 mg **TDS**. Titrate up weekly. Target 1800 - 3600 mg/day in divided doses.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** 30-59, Max 1400 mg/day. If **eGFR** 15-29, Max 700 mg/day. If **eGFR** < 15, Max 300 mg/day.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Neurontin, Pendine", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (100, 300, 400 mg). Tablets (600, 800 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for neuropathic pain/epilepsy.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Neuropathic pain (diabetic neuropathy, post-herpetic neuralgia), focal seizures.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Restless legs syndrome, severe anxiety, alcohol withdrawal adjunct.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "First-line baseline agent for nerve pain. Less abuse potential than Pregabalin.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — None strictly absolute, but severe caution in respiratory failure or end-stage renal disease without dose adjustment.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Gabapentin pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Opioids. The combination of Gabapentin + Oxycodone/Morphine is a leading cause of accidental respiratory overdose in chronic pain patients.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Antacids (Magnesium/Aluminium) physically block absorption in the gut. Separate by 2 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and routine **eGFR** to calculate safe maximum dose.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Assess for falls risk in the elderly, as ataxia and dizziness are severe during week 1.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Inverse Absorption", + "val": "Gabapentin requires a specific amino acid transporter to cross the gut wall. This transporter gets saturated quickly. If you swallow 300mg, 60% absorbs. If you swallow 1200mg at once, only 20% absorbs. You MUST divide the dose TDS to get the drug into the blood.", + "tags": [] + }, + { + "key": "The Renal Coma", + "val": "An elderly patient with an eGFR of 20 given 600mg of Gabapentin TDS will be totally unrousable and apnoeic within 3 days. Always check the kidneys.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Despite the name, it does NOT bind to GABA receptors. It binds to the alpha-2-delta subunit of voltage-gated calcium channels in the spinal cord, halting the release of excitatory neurotransmitters (glutamate, substance P) in pain pathways.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks for full neuropathic pain relief.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5-7 hours. Zero hepatic metabolism. 100% renally excreted unchanged.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - NEURONTIN/GABAPENTIN SANDOZ ARTG/PI and PBS search checked 2026-05-10 for mood-stabiliser/anticonvulsant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha-2-delta ligand — Gabapentinoid." + }, + { + "label": "Route / Formulation", + "value": "Capsules (100, 300, 400 mg). Tablets (600, 800 mg). (Neurontin, Pendine)" + }, + { + "label": "Usual Dose & Max", + "value": "Day 1: **PO** 300 mg **OD**. Day 2: 300 mg **BD**. Day 3: 300 mg **TDS**. Titrate up weekly. Target 1800 - 3600 mg/day in divided doses. Max **3600 mg/day** (e.g., 1200 mg TDS)." + }, + { + "label": "Key Indication Doses", + "value": "Neuropathic Pain: Day 1: **PO** 300 mg **OD**. Day 2: 300 mg **BD**. Day 3: 300 mg **TDS**. Titrate up weekly. Target 1800 - 3600 mg/day in divided doses. Renal Impairment: If **eGFR** 30-59, Max 1400 mg/day. If **eGFR** 15-29, Max 700 mg/day. If **eGFR** < 15, Max 300 mg/day." + }, + { + "label": "Best Uses", + "value": "Gabapentin is an anticonvulsant widely used for neuropathic pain, but has limited evidence for many off-label uses and increasing Schedule 8 restrictions due to misuse and dependence potential." + }, + { + "label": "Avoid / Cautions", + "value": "None strictly absolute, but severe caution in respiratory failure or end-stage renal disease without dose adjustment. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Neurological: Somnolence, dizziness, ataxia, fatigue (Extremely common, requires glacial titration). Respiratory: Severe respiratory depression (Only a major risk if combined with opioids/benzos or in unadjusted renal failure). Metabolic: Weight gain, peripheral edema." + }, + { + "label": "Key Interactions", + "value": "Opioids. The combination of Gabapentin + Oxycodone/Morphine is a leading cause of accidental respiratory overdose in chronic pain patients. Antacids (Magnesium/Aluminium) physically block absorption in the gut. Separate by 2 hours." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **eGFR** to calculate safe maximum dose. Assess for falls risk in the elderly, as ataxia and dizziness are severe during week 1." + }, + { + "label": "Clinical Pearl", + "value": "Gabapentin requires a specific amino acid transporter to cross the gut wall. This transporter gets saturated quickly. If you swallow 300mg, 60% absorbs. If you swallow 1200mg at once, only 20% absorbs. You MUST divide the dose TDS to get the drug into the blood." + } + ] + }, + { + "slug": "lamotrigine", + "name": "Lamotrigine", + "class": "Mood Stabiliser", + "subclass": "Phenyltriazine", + "category": "Neurology - Anticonvulsants", + "accent": "#0891b2", + "tag": "MOOD STAB", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "200-400 mg", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "33 h", + "cls": "", + "flag": "" + }, + { + "label": "SJS/TEN Rash", + "value": "RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Titration", + "value": "SLOW", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Broad-spectrum anticonvulsant. The absolute gold-standard mood stabiliser for Bipolar Depression. Exceptionally well tolerated long-term, but carries a terrifying risk of fatal skin detachment if started too fast.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **200-400 mg/day** (Titration MUST take 6-8 weeks).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The patient must understand that ANY rash in the first 8 weeks requires immediate cessation of the drug and ED review.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Lamotrigine is a well-tolerated anticonvulsant and mood stabiliser (bipolar depression), but requires extremely slow titration to avoid life-threatening Stevens-Johnson Syndrome.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Dermatological", + "val": "CRITICAL — Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN). Risk is ~1 in 1000. Risk skyrockets if starting dose is too high, titration is too fast, or if combined with Valproate.", + "tags": [] + }, + { + "key": "Neurological", + "val": "LOW — Dizziness, headache, ataxia, diplopia (mostly dose-related).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "SAFE — Weight neutral, zero sedation, zero cognitive blunting (unlike Lithium/Valproate).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Bipolar Depression / Epilepsy (Standard)", + "val": "Weeks 1-2: 25 mg **OD**. Weeks 3-4: 50 mg **OD**. Week 5: 100 mg **OD**. Target 200 mg/day.", + "tags": [] + }, + { + "key": "With Valproate (Inhibitor)", + "val": "MANDATORY — Halve the speed. 25 mg on ALTERNATE days for 2 weeks, then 25 mg daily.", + "tags": [] + }, + { + "key": "With Carbamazepine (Inducer)", + "val": "MANDATORY — Double the speed. 50 mg daily for 2 weeks, then 100 mg daily.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lamictal, Lamidus", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Dispersible/Chewable tablets (25 mg, 50 mg, 100 mg, 200 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention of depressive episodes in Bipolar I and II, focal and generalized epilepsy.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Useless for acute mania (takes 2 months to work). The best drug available for keeping bipolar patients out of suicidal depression.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of Lamotrigine-induced rash.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category D. Use only after specialist benefit-risk review; pregnancy can change lamotrigine exposure, so seizure/mood stability and dose/level review may be required.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Lamotrigine pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Valproate heavily inhibits glucuronidation, doubling Lamotrigine levels and guaranteeing SJS. Must use the specialized 'Blue' titration pack.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Carbamazepine/Phenytoin induce clearance, halving Lamotrigine levels. Must use the 'Green' pack.", + "tags": [] + }, + { + "key": "Endocrine", + "val": "HIGH — The combined oral contraceptive pill (COCP) halves lamotrigine blood levels. If the woman stops the pill for the placebo week, lamotrigine levels spike, causing acute neurotoxicity (ataxia/double vision).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn patient: 'If you get any rash, sore mouth, or inflamed eyes in the first two months, stop the pills and go to hospital.'", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required (TDM is rarely useful outside of pregnancy).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "monitor", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 5-Day Restart Rule", + "val": "If a patient forgets to take their Lamotrigine for 5 days in a row, they have lost their tolerance. You CANNOT restart them on 200mg. You must start from the very beginning (25mg) and spend 6 weeks titrating up again, or they will get SJS.", + "tags": [] + }, + { + "key": "The 'Not Working' Complaint", + "val": "Because the titration is so slow, patients in severe depression will complain at week 3 that the drug 'isn't working'. Reassure them that 50mg is a sub-therapeutic placebo dose; the real effect starts at 100-200mg in week 6.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Blocks voltage-gated sodium channels, suppressing the rapid firing of neurons. Decreases presynaptic glutamate release.", + "tags": [] + }, + { + "key": "Onset", + "val": "WEEKS. (Requires glacial titration).", + "tags": [] + }, + { + "key": "Half-life", + "val": "33 hours (Hepatically metabolised via glucuronidation).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - LAMICTAL ARTG/PI and PBS search checked 2026-05-10 for mood-stabiliser/anticonvulsant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Phenyltriazine — Broad-spectrum anticonvulsant." + }, + { + "label": "Route / Formulation", + "value": "Dispersible/Chewable tablets (25 mg, 50 mg, 100 mg, 200 mg). (Lamictal, Lamidus)" + }, + { + "label": "Usual Dose & Max", + "value": "Weeks 1-2: 25 mg **OD**. Weeks 3-4: 50 mg **OD**. Week 5: 100 mg **OD**. Target 200 mg/day. Max **200-400 mg/day** (Titration MUST take 6-8 weeks)." + }, + { + "label": "Key Indication Doses", + "value": "Bipolar Depression / Epilepsy (Standard): Weeks 1-2: 25 mg **OD**. Weeks 3-4: 50 mg **OD**. Week 5: 100 mg **OD**. Target 200 mg/day. With Valproate (Inhibitor): Halve the speed. 25 mg on ALTERNATE days for 2 weeks, then 25 mg daily. With Carbamazepine (Inducer): Double the speed. 50 mg daily for 2 weeks, then 100 mg daily." + }, + { + "label": "Best Uses", + "value": "Lamotrigine is a well-tolerated anticonvulsant and mood stabiliser (bipolar depression), but requires extremely slow titration to avoid life-threatening Stevens-Johnson Syndrome." + }, + { + "label": "Avoid / Cautions", + "value": "History of Lamotrigine-induced rash. **Pregnancy** Category D (Historically), but modern registry data proves it is one of the SAFEST mood stabilisers in pregnancy. However, estrogen (OCP/pregnancy) rapidly clears lamotrigine, requiring the dose to be doubled or tripled to prevent seizures/relapse." + }, + { + "label": "Key Risks", + "value": "Dermatological: Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN). Risk is ~1 in 1000. Risk skyrockets if starting dose is too high, titration is too fast, or if combined with Valproate. Neurological: Dizziness, headache, ataxia, diplopia (mostly dose-related). Metabolic: Weight neutral, zero sedation, zero cognitive blunting (unlike Lithium/Valproate)." + }, + { + "label": "Key Interactions", + "value": "Valproate heavily inhibits glucuronidation, doubling Lamotrigine levels and guaranteeing SJS. Must use the specialized 'Blue' titration pack. Carbamazepine/Phenytoin induce clearance, halving Lamotrigine levels. Must use the 'Green' pack. The combined oral contraceptive pill (COCP) halves lamotrigine blood levels. If the woman stops the pill for the placebo week, lamotrigine levels spike, causing acute neurotoxicity (ataxia/double vision)." + }, + { + "label": "Monitoring", + "value": "Warn patient: 'If you get any rash, sore mouth, or inflamed eyes in the first two months, stop the pills and go to hospital.'. No specific routine laboratory tests required (TDM is rarely useful outside of pregnancy)." + }, + { + "label": "Clinical Pearl", + "value": "If a patient forgets to take their Lamotrigine for 5 days in a row, they have lost their tolerance. You CANNOT restart them on 200mg. You must start from the very beginning (25mg) and spend 6 weeks titrating up again, or they will get SJS." + } + ] + }, + { + "slug": "levetiracetam", + "name": "Levetiracetam", + "class": "Anticonvulsant", + "subclass": "SV2A Ligand", + "category": "Neurology - Anticonvulsants", + "accent": "#0891b2", + "tag": "ANTICONVULSANT", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "3000 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6-8 h", + "cls": "", + "flag": "" + }, + { + "label": "Psych Risk", + "value": "KEPPRA RAGE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Broad-spectrum anticonvulsant. The most commonly prescribed first-line seizure medication on the ward due to its lack of hepatic drug interactions and rapid IV loading capability.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **3000 mg/day** (given in divided doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Renally cleared. Causes severe, uncharacteristic psychiatric side effects (aggression/rage) in a minority of patients.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Levetiracetam is a first-line broad-spectrum anticonvulsant with minimal drug interactions and no monitoring, but commonly causes behavioural disturbance including irritability and aggression.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Psychiatric", + "val": "HIGH — 'Keppra Rage': irritability, severe aggression, depression, psychosis, suicidal ideation (affects ~10% of patients).", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Somnolence, asthenia (weakness), dizziness (mostly during initiation).", + "tags": [] + }, + { + "key": "Hepatic", + "val": "SAFE — Zero hepatic enzyme induction or inhibition.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "info", + "severity": "info", + "note": "Existing row describes absence of hepatic enzyme induction or inhibition; highlight as information only." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Status Epilepticus / Acute Load", + "val": "**IV** 40-60 mg/kg STAT (Max 4500 mg load). Infuse over 15 mins.", + "tags": [] + }, + { + "key": "Epilepsy Maintenance", + "val": "**PO** 250-500 mg **BD**. Titrate every 2 weeks to Max **3000 mg/day**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** 30-50, Max 750 mg BD. If **eGFR** < 30, Max 500 mg BD.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Keppra", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (250, 500, 1000 mg). Oral liquid (100 mg/mL).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (500 mg/5 mL) for **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Focal and generalized seizures, status epilepticus.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The gold standard for acute ward seizure prophylaxis post-TBI, stroke, or craniotomy. Displacing Phenytoin due to a vastly superior safety profile.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Previous severe hypersensitivity or severe psychiatric reaction to the drug.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3. Use only after specialist benefit-risk review; seizure control and dose/level review may be required if exposure changes during pregnancy.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Levetiracetam pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Essentially zero drug-drug interactions. Safe to mix with all other anticonvulsants, OCPs, and DOACs.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ask family/patient specifically about mood changes or aggressive outbursts. If present, switch to Brivaracetam or Sodium Valproate.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** to guide dosing.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 'Brivaracetam' Upgrade", + "val": "If a patient's seizures are perfectly controlled on Levetiracetam but they are experiencing severe 'Keppra Rage', switch them overnight to Brivaracetam (Briviact). It hits the same receptor but is significantly more lipophilic, causing a fraction of the psychiatric side effects.", + "tags": [] + }, + { + "key": "No TDM Needed", + "val": "Unlike Phenytoin or Valproate, routine therapeutic drug monitoring (**TDM**) is completely unnecessary for Levetiracetam.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to Synaptic Vesicle Protein 2A (SV2A), modulating neurotransmitter release and preventing hypersynchronization of epileptiform bursts.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 15 mins. **PO** 1 hour.", + "tags": [] + }, + { + "key": "Half-life", + "val": "6-8 hours. Zero hepatic metabolism. 66% excreted unchanged in urine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - KEPPRA ARTG/PI and PBS search checked 2026-05-10 for mood-stabiliser/anticonvulsant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SV2A Ligand — Broad-spectrum anticonvulsant." + }, + { + "label": "Route / Formulation", + "value": "Tablets (250, 500, 1000 mg). Oral liquid (100 mg/mL). (Keppra)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 40-60 mg/kg STAT (Max 4500 mg load). Infuse over 15 mins." + }, + { + "label": "Key Indication Doses", + "value": "Status Epilepticus / Acute Load: **IV** 40-60 mg/kg STAT (Max 4500 mg load). Infuse over 15 mins. Epilepsy Maintenance: **PO** 250-500 mg **BD**. Titrate every 2 weeks to Max **3000 mg/day**. Renal Impairment: If **eGFR** 30-50, Max 750 mg BD. If **eGFR** < 30, Max 500 mg BD." + }, + { + "label": "Best Uses", + "value": "Levetiracetam is a first-line broad-spectrum anticonvulsant with minimal drug interactions and no monitoring, but commonly causes behavioural disturbance including irritability and aggression." + }, + { + "label": "Avoid / Cautions", + "value": "Previous severe hypersensitivity or severe psychiatric reaction to the drug. **Pregnancy** Category B3. One of the safest anticonvulsants in pregnancy alongside Lamotrigine. Clearance increases during pregnancy, requiring dose escalation." + }, + { + "label": "Key Risks", + "value": "Psychiatric: 'Keppra Rage': irritability, severe aggression, depression, psychosis, suicidal ideation (affects ~10% of patients). Neurological: Somnolence, asthenia (weakness), dizziness (mostly during initiation). Hepatic: Zero hepatic enzyme induction or inhibition." + }, + { + "label": "Key Interactions", + "value": "Essentially zero drug-drug interactions. Safe to mix with all other anticonvulsants, OCPs, and DOACs." + }, + { + "label": "Monitoring", + "value": "Ask family/patient specifically about mood changes or aggressive outbursts. If present, switch to Brivaracetam or Sodium Valproate. Check **eGFR** to guide dosing." + }, + { + "label": "Clinical Pearl", + "value": "If a patient's seizures are perfectly controlled on Levetiracetam but they are experiencing severe 'Keppra Rage', switch them overnight to Brivaracetam (Briviact). It hits the same receptor but is significantly more lipophilic, causing a fraction of the psychiatric side effects." + } + ] + }, + { + "slug": "phenytoin", + "name": "Phenytoin", + "class": "Anticonvulsant", + "subclass": "Hydantoin", + "category": "Neurology - Anticonvulsants", + "accent": "#0891b2", + "tag": "ANTICONVULSANT", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated via TDM", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "22 h (Non-linear)", + "cls": "", + "flag": "" + }, + { + "label": "Toxicity", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Zero-Order", + "value": "KINETICS", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ancient, highly complex sodium-channel blocker. Exhibits non-linear (zero-order) kinetics, meaning a tiny dose increase can cause a massive, toxic spike in blood levels.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Maintenance is usually 300-400 mg/day. Strictly guided by **TDM**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "IV Phenytoin is intensely caustic. Rapid infusion causes fatal arrhythmias and 'Purple Glove Syndrome'.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Phenytoin is a potent anticonvulsant for status epilepticus and seizure prophylaxis, but has zero-order kinetics making dosing treacherous, and requires therapeutic drug monitoring and causes gingival hyperplasia.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Nystagmus (first sign of toxicity), ataxia, slurred speech, confusion, coma.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CRITICAL — Hypotension, severe bradycardia, AV block, asystole (if pushed IV > 50 mg/min).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "HIGH — Gingival hyperplasia, hirsutism, coarsening of facial features. SJS/TEN. Purple Glove Syndrome (tissue necrosis from IV extravasation).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Status Epilepticus (Load)", + "val": "**IV** 15-20 mg/kg. MUST infuse extremely slowly (Max 50 mg/minute) with continuous ECG monitoring.", + "tags": [] + }, + { + "key": "Maintenance", + "val": "**PO** 300 mg **OD** or divided. Adjust by NO MORE than 25-50 mg increments.", + "tags": [] + }, + { + "key": "Enteral Feeding (NGT)", + "val": "CRITICAL — Enteral feeds bind Phenytoin. Feeds must be stopped 2 hours before and 2 hours after the dose, or absorption will be zero.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dilantin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (30 mg, 100 mg). Chewable tablets (50 mg). Oral liquid.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (250 mg/5 mL) for **IV** use. Do NOT give IM (crystallizes in muscle).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Status epilepticus, generalized tonic-clonic seizures, focal seizures.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Largely superseded by Levetiracetam for ward loading due to extreme toxicity, but remains a vital second-line agent in status epilepticus.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — 2nd/3rd degree heart block, sinus bradycardia.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Causes Fetal Hydantoin Syndrome (cleft lip/palate, microcephaly).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Phenytoin pregnancy row remains a source-backed high-risk/contraindication prompt." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Broad-spectrum enzyme INDUCER (CYP3A4, CYP2C9). Obliterates blood levels of OCPs, DOACs, Warfarin, and Quetiapine.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Highly protein bound. Valproate will knock Phenytoin off albumin, causing 'free' (active) Phenytoin levels to spike and cause toxicity, even while total Phenytoin lab levels look normal.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **TDM** (Target Total: 40-80 umol/L. Target Free: 4-8 umol/L). Check Albumin; low albumin artificially lowers total phenytoin levels, hiding toxicity. **LFTs** and **FBC**.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "MANDATORY — Continuous **ECG** and **BP** monitoring during IV loading.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Saline Rule", + "val": "IV Phenytoin precipitates instantly if it touches glucose/dextrose. It MUST be flushed and mixed exclusively with Normal Saline.", + "tags": [] + }, + { + "key": "The Nystagmus Check", + "val": "If a patient on Phenytoin complains of being 'wobbly' or dizzy, ask them to track your finger side-to-side. If their eyes beat wildly (nystagmus), they are toxic. Hold the dose immediately.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prolongs the inactivated state of voltage-gated sodium channels, limiting repetitive firing of action potentials.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 15-30 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Varies wildly (average 22 hours). At therapeutic levels, hepatic enzymes become saturated. Any further dose increase causes levels to skyrocket (Zero-Order Kinetics). Highly protein-bound (90%).", + "tags": [] + } + ] + }, + { + "title": "Special Populations", + "type": "spec", + "rows": [ + { + "key": "Elderly", + "val": "MANDATORY — Phenytoin has markedly reduced protein binding in the elderly (hypoalbuminaemia). A 'therapeutic' total level (10-20 mg/L) in an elderly patient may represent a toxic free fraction. Correct for albumin: Corrected Phenytoin = Measured / (0.2 x Albumin + 0.1). Target corrected level.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "HIGH — Same protein binding issue as elderly; hypoalbuminaemia in renal failure causes high free fractions. Use corrected or free Phenytoin levels. Phenytoin may also worsen renal bone disease.", + "tags": [], + "patient": { + "factors": ["renal", "elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + }, + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CRITICAL — **Pregnancy** Category D. Fetal hydantoin syndrome (midface hypoplasia, distal phalangeal hypoplasia, growth restriction, cardiac defects). Phenytoin metabolism increases significantly during pregnancy — levels drop and seizure control is lost. Monitor levels monthly.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Hepatic Impairment", + "val": "HIGH — Phenytoin is extensively hepatically metabolised (CYP2C9). Any significant hepatic impairment dramatically raises free levels. Halve the dose in moderate impairment; avoid in severe.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DILANTIN ARTG/PI and PBS search checked 2026-05-10 for mood-stabiliser/anticonvulsant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Hydantoin — Ancient, highly complex sodium-channel blocker." + }, + { + "label": "Route / Formulation", + "value": "Capsules (30 mg, 100 mg). Chewable tablets (50 mg). Oral liquid. (Dilantin)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 15-20 mg/kg. MUST infuse extremely slowly (Max 50 mg/minute) with continuous ECG monitoring. Maintenance is usually 300-400 mg/day. Strictly guided by **TDM**." + }, + { + "label": "Key Indication Doses", + "value": "Status Epilepticus (Load): **IV** 15-20 mg/kg. MUST infuse extremely slowly (Max 50 mg/minute) with continuous ECG monitoring. Maintenance: **PO** 300 mg **OD** or divided. Adjust by NO MORE than 25-50 mg increments. Enteral Feeding (NGT): Enteral feeds bind Phenytoin. Feeds must be stopped 2 hours before and 2 hours after the dose, or absorption will be zero." + }, + { + "label": "Best Uses", + "value": "Phenytoin is a potent anticonvulsant for status epilepticus and seizure prophylaxis, but has zero-order kinetics making dosing treacherous, and requires therapeutic drug monitoring and causes gingival hyperplasia." + }, + { + "label": "Avoid / Cautions", + "value": "2nd/3rd degree heart block, sinus bradycardia. **Pregnancy** Category D. Causes Fetal Hydantoin Syndrome (cleft lip/palate, microcephaly)." + }, + { + "label": "Key Risks", + "value": "Neurological: Nystagmus (first sign of toxicity), ataxia, slurred speech, confusion, coma. Cardiovascular: Hypotension, severe bradycardia, AV block, asystole (if pushed IV > 50 mg/min). Dermatological: Gingival hyperplasia, hirsutism, coarsening of facial features. SJS/TEN. Purple Glove Syndrome (tissue necrosis from IV extravasation)." + }, + { + "label": "Key Interactions", + "value": "Broad-spectrum enzyme INDUCER (CYP3A4, CYP2C9). Obliterates blood levels of OCPs, DOACs, Warfarin, and Quetiapine. Highly protein bound. Valproate will knock Phenytoin off albumin, causing 'free' (active) Phenytoin levels to spike and cause toxicity, even while total Phenytoin lab levels look normal." + }, + { + "label": "Monitoring", + "value": "**TDM** (Target Total: 40-80 umol/L. Target Free: 4-8 umol/L). Check Albumin; low albumin artificially lowers total phenytoin levels, hiding toxicity. **LFTs** and **FBC**. Continuous **ECG** and **BP** monitoring during IV loading." + }, + { + "label": "Clinical Pearl", + "value": "IV Phenytoin precipitates instantly if it touches glucose/dextrose. It MUST be flushed and mixed exclusively with Normal Saline." + } + ] + }, + { + "slug": "pregabalin", + "name": "Pregabalin", + "class": "Anxiolytic", + "subclass": "Alpha-2-delta ligand", + "category": "Neurology - Anticonvulsants", + "accent": "#0891b2", + "tag": "GABAPENTINOID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "600 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6 h", + "cls": "", + "flag": "" + }, + { + "label": "Misuse Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The highly potent successor to Gabapentin. Superior, predictable absorption. Exceptional for neuropathic pain and severe anxiety, but plagued by a massive epidemic of street diversion and abuse.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **600 mg/day** (Usually 150-300 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Induces intense euphoria in high doses. Highly sought after by addicts to amplify the 'high' of opioids.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Pregabalin is effective for neuropathic pain, generalised anxiety, and fibromyalgia, but is now Schedule 8 due to high misuse and dependence potential and causes significant dizziness and weight gain.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Euphoria, high addiction/abuse potential. HIGH — Dizziness, severe somnolence, ataxia, withdrawal syndrome if stopped abruptly.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "CRITICAL — Synergistic respiratory depression with opioids.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Significant weight gain, peripheral edema.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Neuropathic Pain", + "val": "Start **PO** 75 mg **BD**. Titrate to 150-300 mg **BD** after 3-7 days. Max 600 mg/day.", + "tags": [] + }, + { + "key": "Generalised Anxiety Disorder (GAD)", + "val": "**PO** 75 mg **BD**, titrate to 300 mg/day.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** 30-60, Max 300 mg/day. If **eGFR** 15-30, Max 150 mg/day. If **eGFR** < 15, Max 75 mg/day.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lyrica", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (25, 75, 150, 300 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for neuropathic pain. High scrutiny on ward and community prescribing due to abuse.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Neuropathic pain, focal seizures.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Generalised Anxiety Disorder (Standard in Europe, off-label in Aus), Restless Legs Syndrome.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Preferred over Gabapentin for efficacy and BD dosing, but avoided in patients with any history of substance abuse.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of severe substance abuse (unless strictly monitored). Severe renal failure without dose adjustment.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Pregabalin pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Opioids, Benzodiazepines, Alcohol. The combination causes profound respiratory arrest and is the leading cause of poly-drug overdose deaths globally.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Look for 'lost scripts' or patients demanding early refills. Do not prescribe 300mg capsules to opioid users unless absolutely clinically necessary.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** to dictate safe dosing limits.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Absorption Upgrade", + "val": "Unlike Gabapentin (which maxes out its absorption transporters in the gut), Pregabalin absorption is linear and >90% at ANY dose. If you swallow 600mg of Pregabalin, 600mg hits your brain. This makes it vastly more effective, but infinitely more abusable.", + "tags": [] + }, + { + "key": "The Opioid Amplifier", + "val": "Addicts use Pregabalin to 'boost' their heroin or methadone. It amplifies the opioid high by 3-5 times, but also amplifies the respiratory depression, causing accidental death.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds the alpha-2-delta subunit of voltage-gated calcium channels in the CNS. Halts the release of excitatory neurotransmitters (Glutamate, Substance P, Noradrenaline).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** Days. (Faster onset than Gabapentin for anxiety/pain).", + "tags": [] + }, + { + "key": "Half-life", + "val": "6 hours. Zero hepatic metabolism. 100% renally excreted unchanged.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - PREGABALIN SANDOZ ARTG/PI and PBS search checked 2026-05-10 for mood-stabiliser/anticonvulsant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha-2-delta ligand — The highly potent successor to Gabapentin." + }, + { + "label": "Route / Formulation", + "value": "Capsules (25, 75, 150, 300 mg). (Lyrica)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 75 mg **BD**. Titrate to 150-300 mg **BD** after 3-7 days. Max 600 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Neuropathic Pain: Start **PO** 75 mg **BD**. Titrate to 150-300 mg **BD** after 3-7 days. Max 600 mg/day. Generalised Anxiety Disorder (GAD): **PO** 75 mg **BD**, titrate to 300 mg/day. Renal Impairment: If **eGFR** 30-60, Max 300 mg/day. If **eGFR** 15-30, Max 150 mg/day. If **eGFR** < 15, Max 75 mg/day." + }, + { + "label": "Best Uses", + "value": "Pregabalin is effective for neuropathic pain, generalised anxiety, and fibromyalgia, but is now Schedule 8 due to high misuse and dependence potential and causes significant dizziness and weight gain." + }, + { + "label": "Avoid / Cautions", + "value": "History of severe substance abuse (unless strictly monitored). Severe renal failure without dose adjustment. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Neurological: Euphoria, high addiction/abuse potential. HIGH — Dizziness, severe somnolence, ataxia, withdrawal syndrome if stopped abruptly. Respiratory: Synergistic respiratory depression with opioids. Metabolic: Significant weight gain, peripheral edema." + }, + { + "label": "Key Interactions", + "value": "Opioids, Benzodiazepines, Alcohol. The combination causes profound respiratory arrest and is the leading cause of poly-drug overdose deaths globally." + }, + { + "label": "Monitoring", + "value": "Look for 'lost scripts' or patients demanding early refills. Do not prescribe 300mg capsules to opioid users unless absolutely clinically necessary. Check **eGFR** to dictate safe dosing limits." + }, + { + "label": "Clinical Pearl", + "value": "Unlike Gabapentin (which maxes out its absorption transporters in the gut), Pregabalin absorption is linear and >90% at ANY dose. If you swallow 600mg of Pregabalin, 600mg hits your brain. This makes it vastly more effective, but infinitely more abusable." + } + ] + }, + { + "slug": "sodium-valproate-oral-iv", + "name": "Sodium valproate (oral/IV)", + "class": "Mood Stabiliser", + "subclass": "Fatty acid derivative", + "category": "Neurology - Anticonvulsants", + "accent": "#0891b2", + "tag": "MOOD STAB", + "schedule": "S4", + "stats": [ + { + "label": "Target Range", + "value": "350–700 umol/L", + "cls": "accent", + "flag": "accent" + }, + { + "label": "Half-life", + "value": "14 h", + "cls": "", + "flag": "" + }, + { + "label": "Teratogenic", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Hepatic", + "value": "MONITOR", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Broad-spectrum anticonvulsant and highly effective mood stabiliser for Bipolar Mania. Extremely dangerous in women of childbearing age.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2500 mg/day** (Titrated to response and blood levels).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The most teratogenic drug in neurology/psychiatry. Causes horrific birth defects and neurodevelopmental destruction.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Sodium valproate (oral/IV) is a broad-spectrum anticonvulsant and mood stabiliser, but is absolutely contraindicated in women of childbearing potential due to teratogenicity and requires hepatic and haematological monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Hepatic", + "val": "CRITICAL — Fatal hepatotoxicity (highest risk in children < 2 years on polytherapy). Hyperammonemic encephalopathy (confusion/coma without elevated LFTs).", + "tags": [], + "patient": { + "factors": ["hepatic", "paediatric"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Haematological", + "val": "HIGH — Thrombocytopenia (low platelets), impaired coagulation.", + "tags": [] + }, + { + "key": "Metabolic/GI", + "val": "HIGH — Significant weight gain, severe nausea (reduced with CR forms), PCOS-like syndrome, hair loss, pancreatitis.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Bipolar Mania", + "val": "Start **PO** 500 mg **BD** (enteric-coated or CR). Titrate rapidly to target range. Maintenance 1000-2000 mg/day.", + "tags": [] + }, + { + "key": "Epilepsy", + "val": "**PO** Start 400-600 mg/day. Increase until seizures are controlled. Max 2500 mg/day.", + "tags": [] + }, + { + "key": "Status Epilepticus", + "val": "**IV** 20-30 mg/kg bolus, then continuous infusion.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Epilim, Epilim CR, Valpro", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Enteric-coated tablets (100, 200, 500 mg). Crushable tablets (100 mg). CR Tablets (200, 500 mg). Oral liquid.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (400 mg powder) for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Special consent forms often mandated for females < 50 yrs.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Bipolar disorder (mania), all forms of epilepsy (generalised and focal).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Migraine prophylaxis.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "First-line for generalized epilepsy in males. First-line for acute bipolar mania.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active liver disease, mitochondrial disorders (POLG mutations), urea cycle disorders.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Existing absolute row names active or severe hepatic disease/failure; highlight when hepatic context is entered." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D (Functionally Category X). Causes neural tube defects (spina bifida) in 10% of cases, and drops the child's IQ by 10 points. MUST NOT be used in women of childbearing age unless all other options have failed and strict dual-contraception is enforced.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Sodium valproate (oral/IV) pregnancy row remains a source-backed high-risk/contraindication prompt." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Lamotrigine. Valproate completely blocks the clearance of Lamotrigine, doubling its levels and causing fatal SJS/TEN. If combining, Lamotrigine dose must be halved and titrated glacially.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Meropenem/Carbapenems. Within 24 hours of starting Meropenem, Valproate levels drop to ZERO. The patient will seize. Avoid combination.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and routine **LFTs**, **FBC** (platelets). Measure **TDM** (Valproate levels, target 350-700 umol/L).", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check Ammonia levels if the patient becomes acutely confused or lethargic (Hyperammonemic encephalopathy).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Platelet Bleed", + "val": "Doses > 1500mg/day often cause thrombocytopenia. Always check a recent FBC before taking a Valproate patient to surgery, or they will bleed out.", + "tags": [] + }, + { + "key": "The Ammonia Coma", + "val": "Valproate shuts down the urea cycle in the liver. Ammonia builds up, crosses the blood-brain barrier, and causes a coma. Liver function tests (AST/ALT) will look completely normal. You must check an Ammonia level. The cure is IV L-Carnitine.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Increases brain concentrations of GABA (inhibitory neurotransmitter). Blocks voltage-gated sodium channels and T-type calcium channels.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** Days for mania. **IV** Minutes for seizures.", + "tags": [] + }, + { + "key": "Half-life", + "val": "14 hours. Highly protein bound. Extensively metabolised by the liver.", + "tags": [] + } + ] + }, + { + "title": "Special Populations", + "type": "spec", + "rows": [ + { + "key": "Pregnancy", + "val": "CRITICAL — **Pregnancy** Category X (effectively). The most teratogenic AED in common use. Risk of neural tube defects (~5%), fetal valproate syndrome (facial anomalies, limb defects, autism). NEVER initiate in a woman of childbearing potential without specialist discussion, documented counselling, and dual contraception under the Australian REMS-equivalent guidelines.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Elderly", + "val": "MANDATORY — Hepatic enzyme activity declines with age. Valproate clearance is reduced. Start at 50% of standard dose and titrate slowly. High risk of confusion, tremor, and falls at standard doses.", + "tags": [], + "patient": { + "factors": ["hepatic", "elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "CAUTION — Protein binding of Valproate is reduced in renal impairment (hypoalbuminaemia). Total plasma levels underestimate the free (active) fraction — a 'normal' total level may represent relative toxicity. Use free Valproate levels if available.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Lactation", + "val": "CAUTION — Low transfer into breast milk (~1-10%). Generally considered compatible with breastfeeding by most guidelines; however, monitor infant for sedation.", + "tags": [], + "patient": { + "factors": ["lactation", "paediatric"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - EPILIM oral/VALPROATE-AFT IV ARTG/PI and PBS search checked 2026-05-10 for mood-stabiliser/anticonvulsant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Fatty acid derivative — Broad-spectrum anticonvulsant and highly effective mood stabiliser for Bipolar Mania." + }, + { + "label": "Route / Formulation", + "value": "Enteric-coated tablets (100, 200, 500 mg). Crushable tablets (100 mg). CR Tablets (200, 500 mg). Oral liquid. (Epilim, Epilim CR, Valpro)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 500 mg **BD** (enteric-coated or CR). Titrate rapidly to target range. Maintenance 1000-2000 mg/day. Max **2500 mg/day** (Titrated to response and blood levels)." + }, + { + "label": "Key Indication Doses", + "value": "Bipolar Mania: Start **PO** 500 mg **BD** (enteric-coated or CR). Titrate rapidly to target range. Maintenance 1000-2000 mg/day. Epilepsy: **PO** Start 400-600 mg/day. Increase until seizures are controlled. Max 2500 mg/day. Status Epilepticus: **IV** 20-30 mg/kg bolus, then continuous infusion." + }, + { + "label": "Best Uses", + "value": "Sodium valproate (oral/IV) is a broad-spectrum anticonvulsant and mood stabiliser, but is absolutely contraindicated in women of childbearing potential due to teratogenicity and requires hepatic and haematological monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Active liver disease, mitochondrial disorders (POLG mutations), urea cycle disorders. **Pregnancy** Category D (Functionally Category X). Causes neural tube defects (spina bifida) in 10% of cases, and drops the child's IQ by 10 points. MUST NOT be used in women of childbearing age unless all other options have failed and strict dual-contraception is enforced." + }, + { + "label": "Key Risks", + "value": "Hepatic: Fatal hepatotoxicity (highest risk in children < 2 years on polytherapy). Hyperammonemic encephalopathy (confusion/coma without elevated LFTs). Haematological: Thrombocytopenia (low platelets), impaired coagulation. Metabolic/GI: Significant weight gain, severe nausea (reduced with CR forms), PCOS-like syndrome, hair loss, pancreatitis." + }, + { + "label": "Key Interactions", + "value": "Lamotrigine. Valproate completely blocks the clearance of Lamotrigine, doubling its levels and causing fatal SJS/TEN. If combining, Lamotrigine dose must be halved and titrated glacially. Meropenem/Carbapenems. Within 24 hours of starting Meropenem, Valproate levels drop to ZERO. The patient will seize. Avoid combination." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **LFTs**, **FBC** (platelets). Measure **TDM** (Valproate levels, target 350-700 umol/L). Check Ammonia levels if the patient becomes acutely confused or lethargic (Hyperammonemic encephalopathy)." + }, + { + "label": "Clinical Pearl", + "value": "Doses > 1500mg/day often cause thrombocytopenia. Always check a recent FBC before taking a Valproate patient to surgery, or they will bleed out." + } + ] + }, + { + "slug": "topiramate", + "name": "Topiramate", + "class": "Neurology", + "subclass": "Anticonvulsant", + "category": "Neurology - Anticonvulsants", + "accent": "#475569", + "tag": "MIGRAINE/SEIZURE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "21 h", + "cls": "", + "flag": "" + }, + { + "label": "Cognitive", + "value": "DOPAMAX", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Weight Loss", + "value": "COMMON", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Broad-spectrum anticonvulsant and migraine prophylactic. Causes significant weight loss and appetite suppression, but is notorious for inducing 'brain fog' and word-finding difficulties.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mg/day** (For epilepsy). Max 100 mg/day (For migraine).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Can precipitate acute angle-closure glaucoma and kidney stones.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Topiramate is a broad-spectrum anticonvulsant also used for migraine prophylaxis and weight loss, but causes significant cognitive dulling, word-finding difficulty, and nephrolithiasis.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Cognitive blunting, word-finding difficulty, memory impairment, paresthesia (tingling in fingers/toes).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Weight loss, anorexia. MODERATE — Non-anion gap metabolic acidosis (due to renal bicarbonate wasting from carbonic anhydrase inhibition).", + "tags": [] + }, + { + "key": "Ocular", + "val": "CRITICAL — Acute secondary angle-closure glaucoma (sudden severe eye pain/blurriness).", + "tags": [] + }, + { + "key": "Renal", + "val": "HIGH — Nephrolithiasis (Calcium phosphate kidney stones).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Migraine Prophylaxis", + "val": "Start **PO** 25 mg **NOCTE**. Titrate up by 25 mg weekly to target 50 mg **BD** (100 mg/day).", + "tags": [] + }, + { + "key": "Epilepsy", + "val": "**PO** 25-50 mg **OD**, titrate up to 100-200 mg **BD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Halve the dose if **eGFR** < 70.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Topamax, Tamate", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (25 mg, 50 mg, 100 mg, 200 mg). Sprinkle capsules.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Migraine prophylaxis, focal and generalized epilepsy.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Weight loss (combined with phentermine), binge eating disorder.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Highly favored in young patients with migraines who wish to avoid weight-gaining drugs (like Valproate or Amitriptyline).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of kidney stones, untreated glaucoma.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. High risk of cleft lip/palate. Must use strict contraception.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Topiramate pregnancy row remains a source-backed high-risk/contraindication prompt." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Endocrine", + "val": "HIGH — Doses > 200mg/day induce CYP3A4, accelerating the clearance of oral contraceptives (OCPs), rendering them ineffective and leading to unplanned pregnancies.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Monitor **U&E** (specifically serum bicarbonate) for metabolic acidosis.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Counsel heavily on maintaining high fluid intake to prevent kidney stones. Ask about eye pain/vision changes.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 'Dopamax' Nickname", + "val": "Topiramate is infamous for causing psychomotor slowing and making patients feel 'stupid'. They will frequently forget mid-sentence what they were saying. Start the dose very low and escalate slowly to mitigate this.", + "tags": [] + }, + { + "key": "Tingling Hands", + "val": "The carbonic anhydrase inhibition causes harmless but annoying paresthesias (pins and needles) in the fingers and toes. Reassure the patient this is a normal side effect, not a stroke or nerve damage.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Blocks voltage-gated sodium channels, enhances GABA-A activity, antagonizes AMPA/kainate glutamate receptors, and weakly inhibits carbonic anhydrase.", + "tags": [] + }, + { + "key": "Onset", + "val": "Weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "21 hours. Cleared 70% unchanged in the urine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TOPAMAX ARTG/PI and PBS search checked 2026-05-10 for mood-stabiliser/anticonvulsant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Anticonvulsant — Broad-spectrum anticonvulsant and migraine prophylactic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (25 mg, 50 mg, 100 mg, 200 mg). Sprinkle capsules. (Topamax, Tamate)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 25 mg **NOCTE**. Titrate up by 25 mg weekly to target 50 mg **BD** (100 mg/day). Max **400 mg/day** (For epilepsy)." + }, + { + "label": "Key Indication Doses", + "value": "Migraine Prophylaxis: Start **PO** 25 mg **NOCTE**. Titrate up by 25 mg weekly to target 50 mg **BD** (100 mg/day). Epilepsy: **PO** 25-50 mg **OD**, titrate up to 100-200 mg **BD**. Renal Impairment: Halve the dose if **eGFR** < 70." + }, + { + "label": "Best Uses", + "value": "Topiramate is a broad-spectrum anticonvulsant also used for migraine prophylaxis and weight loss, but causes significant cognitive dulling, word-finding difficulty, and nephrolithiasis." + }, + { + "label": "Avoid / Cautions", + "value": "History of kidney stones, untreated glaucoma. **Pregnancy** Category D. High risk of cleft lip/palate. Must use strict contraception." + }, + { + "label": "Key Risks", + "value": "Neurological: Cognitive blunting, word-finding difficulty, memory impairment, paresthesia (tingling in fingers/toes). Metabolic: Weight loss, anorexia. MODERATE — Non-anion gap metabolic acidosis (due to renal bicarbonate wasting from carbonic anhydrase inhibition). Ocular: Acute secondary angle-closure glaucoma (sudden severe eye pain/blurriness). Renal: Nephrolithiasis (Calcium phosphate kidney stones)." + }, + { + "label": "Key Interactions", + "value": "Doses > 200mg/day induce CYP3A4, accelerating the clearance of oral contraceptives (OCPs), rendering them ineffective and leading to unplanned pregnancies." + }, + { + "label": "Monitoring", + "value": "Monitor **U&E** (specifically serum bicarbonate) for metabolic acidosis. Counsel heavily on maintaining high fluid intake to prevent kidney stones. Ask about eye pain/vision changes." + }, + { + "label": "Clinical Pearl", + "value": "Topiramate is infamous for causing psychomotor slowing and making patients feel 'stupid'. They will frequently forget mid-sentence what they were saying. Start the dose very low and escalate slowly to mitigate this." + } + ] + }, + { + "slug": "sumatriptan", + "name": "Sumatriptan", + "class": "Neurology", + "subclass": "Triptan", + "category": "Neurology - Migraine", + "accent": "#475569", + "tag": "5HT1 AGONIST", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg/day (PO)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "Coronary Spasm", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Timing", + "value": "AT ONSET", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Serotonin (5-HT1B/1D) receptor agonist. Powerful cranial vasoconstrictor. The definitive acute abortive agent for severe migraines and cluster headaches.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg/day** (**PO**) or **12 mg/day** (**SC**).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never prescribe to patients with ischemic heart disease. It can trigger lethal coronary artery vasospasm and myocardial infarction.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Sumatriptan is the gold-standard triptan for acute migraine relief, but is contraindicated in ischaemic heart disease and must not be used within 24 hours of ergotamines or other triptans.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Coronary artery vasospasm, myocardial infarction, severe hypertension, arrhythmias.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — 'Triptan Sensations' (tightness, heaviness, pain or pressure in the chest, throat, and neck), dizziness, tingling.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Nausea (though the migraine itself causes this).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Migraine (Oral)", + "val": "**PO** 50 mg STAT as soon as headache begins. May repeat dose after 2 hours if migraine returns. Max 300 mg/24h.", + "tags": [] + }, + { + "key": "Acute Migraine (Subcutaneous)", + "val": "**SC** 6 mg STAT via autoinjector. Max 12 mg/24h. (Rapid acting, bypasses GI stasis/vomiting).", + "tags": [] + }, + { + "key": "Cluster Headache", + "val": "**SC** 6 mg STAT.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Imigran", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (50 mg). Nasal spray (10 mg, 20 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled autoinjector pens (6 mg/0.5 mL) for **SC** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute relief of migraine attacks (with or without aura), acute treatment of cluster headaches (SC/Nasal only).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Used strictly as an abortive therapy. Useless for migraine prophylaxis.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Ischaemic heart disease, coronary vasospasm/Prinzmetal angina, previous MI, stroke/TIA, peripheral vascular disease, uncontrolled hypertension, severe hepatic impairment, hemiplegic/basilar/brainstem migraine, MAOIs, and ergot/triptan use within 24 hours.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Sumatriptan is contraindicated in severe hepatic impairment." + } + }, + { + "key": "Absolute", + "val": "CRITICAL — Concurrent use of Ergotamine derivatives or MAOIs.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3; use only after benefit-risk review when migraine severity justifies treatment.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Sumatriptan in pregnancy requires individual benefit-risk review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CAUTION — Serotonergic medicines such as SSRIs, SNRIs, and tramadol rarely cause serotonin toxicity with triptans; counsel and monitor. MAOIs remain contraindicated.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Ergotamines (e.g., Cafergot). Risk of prolonged, severe vasospasm. Must separate by 24 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MONITOR — Chest/throat tightness can occur, but severe, persistent, or crushing chest pain, dyspnoea, syncope, or neurologic deficit needs urgent assessment.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Aura Trap", + "val": "Triptans do not work if taken during the 'aura' phase of a migraine. The patient must wait until the actual *headache pain* begins before taking the pill, otherwise it is wasted.", + "tags": [] + }, + { + "key": "The Gastric Stasis Rescue", + "val": "During a severe migraine, the stomach completely stops moving (gastric stasis). If a patient takes an oral pill, it sits in the stomach unabsorbed and they vomit it up. The **SC** autoinjector or Nasal spray entirely bypasses the gut and is infinitely more effective in severe attacks.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selective agonist at 5-HT1B and 5-HT1D receptors on cranial blood vessels and sensory nerves of the trigeminal system. Causes direct cranial vasoconstriction and blocks the release of pro-inflammatory neuropeptides (CGRP).", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 10-15 mins. **Nasal** 15 mins. **PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2 hours. Hepatically metabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: IMIGRAN sumatriptan Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Triptan — Serotonin (5-HT1B/1D) receptor agonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (50 mg). Nasal spray (10 mg, 20 mg). (Imigran)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 50 mg STAT as soon as headache begins. May repeat dose after 2 hours if migraine returns. Max 300 mg/24h." + }, + { + "label": "Key Indication Doses", + "value": "Acute Migraine (Oral): **PO** 50 mg STAT as soon as headache begins. May repeat dose after 2 hours if migraine returns. Max 300 mg/24h. Acute Migraine (Subcutaneous): **SC** 6 mg STAT via autoinjector. Max 12 mg/24h. (Rapid acting, bypasses GI stasis/vomiting). Cluster Headache: **SC** 6 mg STAT." + }, + { + "label": "Best Uses", + "value": "Sumatriptan is the gold-standard triptan for acute migraine relief, but is contraindicated in ischaemic heart disease and must not be used within 24 hours of ergotamines or other triptans." + }, + { + "label": "Avoid / Cautions", + "value": "Ischaemic heart disease, coronary vasospasm/Prinzmetal angina, previous MI, stroke/TIA, peripheral vascular disease, uncontrolled hypertension, severe hepatic impairment, hemiplegic/basilar/brainstem migraine, MAOIs, and ergot/triptan use within 24 hours. Pregnancy requires benefit-risk review." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Coronary artery vasospasm, myocardial infarction, severe hypertension, arrhythmias. Neurological: 'Triptan Sensations' (tightness, heaviness, pain or pressure in the chest, throat, and neck), dizziness, tingling. Gastrointestinal: Nausea (though the migraine itself causes this)." + }, + { + "label": "Key Interactions", + "value": "SSRIs, SNRIs, MAOIs, Tramadol. Major risk of Serotonin Syndrome. Ergotamines (e.g., Cafergot). Risk of prolonged, severe vasospasm. Must separate by 24 hours." + }, + { + "label": "Monitoring", + "value": "Educate the patient that 'chest tightness' is a normal, harmless side effect of the drug's mechanism on esophageal/muscle receptors, but true crushing chest pain requires ED review. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Triptans do not work if taken during the 'aura' phase of a migraine. The patient must wait until the actual *headache pain* begins before taking the pill, otherwise it is wasted." + } + ] + }, + { + "slug": "alprazolam", + "name": "Alprazolam", + "class": "Benzodiazepine", + "subclass": "Short-acting potent", + "category": "Neurology - Sedatives & Hypnotics", + "accent": "#6366f1", + "tag": "BENZO", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "4 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "11-15 h", + "cls": "", + "flag": "" + }, + { + "label": "Dependence", + "value": "SEVERE", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Rebound Panic", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent, short-acting triazolobenzodiazepine. Unmatched for rapid termination of severe panic attacks, but carries the highest addiction, abuse, and withdrawal risk of the entire class.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 mg/day** (Usually 0.5 - 1 mg per dose).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Up-scheduled to S8 in Australia due to massive abuse. Prescribing on the ward is extremely restricted and generally avoided.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Alprazolam is a short-acting benzodiazepine for panic disorder and acute anxiety, but has the highest dependence and withdrawal seizure risk of all benzodiazepines.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Extreme psychological euphoria and physical dependence. CRITICAL — Violent withdrawal seizures if stopped abruptly. HIGH — 'Rebound Anxiety' (When the dose wears off in 4 hours, the panic comes back worse than before).", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Respiratory depression (fatal with opioids).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Panic Disorder", + "val": "**PO** 0.25 - 0.5 mg **TDS**. Max 4 mg/day.", + "tags": [] + }, + { + "key": "Anxiety", + "val": "**PO** 0.25 mg **BD** to **TDS**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Xanax, Kalma, Alprax", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (250 mcg, 500 mcg, 1 mg, 2 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8). Private script only in most states.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Panic disorder with/without agoraphobia, severe anxiety disorders.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Largely blacklisted for routine use. Reserved for patients already dependent on it, or extreme, refractory panic disorder under psychiatric care.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Substance abuse history, severe respiratory failure, Myasthenia Gravis.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Associated with congenital malformations and severe neonatal withdrawal.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Alprazolam pregnancy row remains a source-backed high-risk/contraindication prompt." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Opioids, Alcohol. Co-ingestion is a primary cause of overdose death.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Strong CYP3A4 inhibitors (Ketoconazole, Clarithromycin) significantly increase Alprazolam toxicity.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — If a patient is admitted taking > 2mg/day chronically, you MUST prescribe it to prevent withdrawal seizures, but seek psychiatric advice to cross-taper to diazepam for safe weaning.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Rebound Trap", + "val": "Because it wears off in 4-6 hours, patients wake up in a state of 'rebound panic'. They take another pill to fix it. This creates a vicious, unbreakable cycle of addiction. Avoid starting it.", + "tags": [] + }, + { + "key": "The S8 Status", + "val": "Due to intense street value and abuse, you cannot legally prescribe this on discharge in WA without an S8 permit, unless continuing an existing verified specialist regimen.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent GABA-A PAM. Binds with very high affinity.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 15-30 mins (Hits the brain very quickly, producing a 'rush' or rapid relief).", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h (Very short).", + "tags": [] + }, + { + "key": "Half-life", + "val": "11-15 hours. Metabolised by CYP3A4 into weakly active metabolites.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - KALMA/ALPRAX ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Short-acting potent — Highly potent, short-acting triazolobenzodiazepine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (250 mcg, 500 mcg, 1 mg, 2 mg). (Xanax, Kalma, Alprax)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 0.25 - 0.5 mg **TDS**. Max 4 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Panic Disorder: **PO** 0.25 - 0.5 mg **TDS**. Max 4 mg/day. Anxiety: **PO** 0.25 mg **BD** to **TDS**." + }, + { + "label": "Best Uses", + "value": "Alprazolam is a short-acting benzodiazepine for panic disorder and acute anxiety, but has the highest dependence and withdrawal seizure risk of all benzodiazepines." + }, + { + "label": "Avoid / Cautions", + "value": "Substance abuse history, severe respiratory failure, Myasthenia Gravis. **Pregnancy** Category D. Associated with congenital malformations and severe neonatal withdrawal." + }, + { + "label": "Key Risks", + "value": "Neurological: Extreme psychological euphoria and physical dependence. CRITICAL — Violent withdrawal seizures if stopped abruptly. HIGH — 'Rebound Anxiety' (When the dose wears off in 4 hours, the panic comes back worse than before). Respiratory: Respiratory depression (fatal with opioids)." + }, + { + "label": "Key Interactions", + "value": "Opioids, Alcohol. Co-ingestion is a primary cause of overdose death. Strong CYP3A4 inhibitors (Ketoconazole, Clarithromycin) significantly increase Alprazolam toxicity." + }, + { + "label": "Monitoring", + "value": "If a patient is admitted taking > 2mg/day chronically, you MUST prescribe it to prevent withdrawal seizures, but seek psychiatric advice to cross-taper to diazepam for safe weaning." + }, + { + "label": "Clinical Pearl", + "value": "Because it wears off in 4-6 hours, patients wake up in a state of 'rebound panic'. They take another pill to fix it. This creates a vicious, unbreakable cycle of addiction. Avoid starting it." + } + ] + }, + { + "slug": "clonazepam", + "name": "Clonazepam", + "class": "Benzodiazepine", + "subclass": "Long-acting", + "category": "Neurology - Sedatives & Hypnotics", + "accent": "#6366f1", + "tag": "BENZO", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "8 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "20-50 h", + "cls": "", + "flag": "" + }, + { + "label": "Potency", + "value": "HIGH", + "cls": "warn", + "flag": "" + }, + { + "label": "Dependence", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent, long-acting benzodiazepine. Exhibits profound anticonvulsant and anxiolytic properties. Less sedating than diazepam but carries a massive risk of physical dependence.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **8 mg/day** (Usually 1-4 mg/day for panic/seizures).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "0.5 mg of Clonazepam is roughly equivalent to 10 mg of Diazepam. Do not miscalculate the potency.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Clonazepam is a long-acting benzodiazepine for epilepsy and panic disorder, but has high dependence potential and abrupt withdrawal can cause life-threatening seizures.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Severe physiological dependence, terrifying withdrawal seizures if stopped abruptly. HIGH — Ataxia, cognitive blunting, somnolence.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Respiratory depression (especially if mixed with opioids).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Panic Disorder", + "val": "**PO** 0.5-1 mg **BD**. Max 4 mg/day.", + "tags": [] + }, + { + "key": "Epilepsy / Myoclonus", + "val": "**PO** 0.5 mg **TDS**. Titrate up slowly based on response. Max 8 mg/day.", + "tags": [] + }, + { + "key": "Status Epilepticus", + "val": "**IV** 1 mg STAT slow push (Often used as second-line to Diazepam/Midazolam).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Rivotril, Paxam", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (500 mcg, 2 mg). Oral liquid drops (2.5 mg/mL).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (1 mg/1 mL) for **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for epilepsy. Private for anxiety.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Epilepsy (myoclonic, absence, focal), severe panic disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "REM sleep behavior disorder, severe acute mania, restless legs syndrome.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Preferred benzo for seizure prevention and chronic panic disorder due to stable blood levels (long half-life prevents inter-dose withdrawal).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe respiratory insufficiency, Myasthenia Gravis, severe hepatic failure.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Elderly / Frail", + "val": "CAUTION — Accumulates over weeks. Can cause stealthy, severe falls/fractures in the elderly. Use Oxazepam instead.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "caution", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Older adults are high-risk for accumulation, sedation, falls, and fractures." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Clonazepam pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Opioids, Alcohol (Fatal respiratory arrest).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — CYP3A4 inhibitors (Clarithromycin, Ketoconazole) spike clonazepam levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for sedation and ataxia. High falls risk on the ward.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Half-Life Trap", + "val": "Because of its 50-hour half-life, the drug takes up to 10 days to reach steady-state. If you increase the dose every 2 days because 'it isn't working', the patient will suddenly fall into a coma on day 8 when the drug finally stacks up.", + "tags": [] + }, + { + "key": "The Secret Taper", + "val": "Clonazepam is so potent and long-acting that it is often the drug used by addiction specialists to taper patients off highly addictive, short-acting benzos like Alprazolam (Xanax).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Positive allosteric modulator of the GABA-A receptor. Increases the frequency of chloride channel opening, hyperpolarizing neurons.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 20-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "12 h (Clinical effect), though blood levels remain for days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "20-50 hours. Extensively hepatically metabolised (CYP3A4) to inactive metabolites.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - RIVOTRIL ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Long-acting — Highly potent, long-acting benzodiazepine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (500 mcg, 2 mg). Oral liquid drops (2.5 mg/mL). (Rivotril, Paxam)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 0.5-1 mg **BD**. Max 4 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Panic Disorder: **PO** 0.5-1 mg **BD**. Max 4 mg/day. Epilepsy / Myoclonus: **PO** 0.5 mg **TDS**. Titrate up slowly based on response. Max 8 mg/day. Status Epilepticus: **IV** 1 mg STAT slow push (Often used as second-line to Diazepam/Midazolam)." + }, + { + "label": "Best Uses", + "value": "Clonazepam is a long-acting benzodiazepine for epilepsy and panic disorder, but has high dependence potential and abrupt withdrawal can cause life-threatening seizures." + }, + { + "label": "Avoid / Cautions", + "value": "Severe respiratory insufficiency, Myasthenia Gravis, severe hepatic failure. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Severe physiological dependence, terrifying withdrawal seizures if stopped abruptly. HIGH — Ataxia, cognitive blunting, somnolence. Respiratory: Respiratory depression (especially if mixed with opioids)." + }, + { + "label": "Key Interactions", + "value": "Opioids, Alcohol (Fatal respiratory arrest). CYP3A4 inhibitors (Clarithromycin, Ketoconazole) spike clonazepam levels." + }, + { + "label": "Monitoring", + "value": "Monitor for sedation and ataxia. High falls risk on the ward. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Because of its 50-hour half-life, the drug takes up to 10 days to reach steady-state. If you increase the dose every 2 days because 'it isn't working', the patient will suddenly fall into a coma on day 8 when the drug finally stacks up." + } + ] + }, + { + "slug": "diazepam", + "name": "Diazepam", + "class": "Benzodiazepine", + "subclass": "Long-acting GABA-A PAM", + "category": "Neurology - Sedatives & Hypnotics", + "accent": "#6366f1", + "tag": "BENZO", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Varies", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "20–100 h", + "cls": "", + "flag": "" + }, + { + "label": "Dependence", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Metabolites", + "value": "ACTIVE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly lipophilic, long-acting benzodiazepine. Rapid onset but features a massive half-life and active metabolites that accumulate in fat and liver tissue over days.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max varies entirely by indication (40 mg/day for anxiety, massive doses >100mg for acute alcohol withdrawal).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Do not use in the elderly or those with severe liver failure. The drug will accumulate, causing a multi-day coma and falls.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Diazepam is a long-acting benzodiazepine for acute anxiety, seizures, and alcohol withdrawal, but accumulates with repeated dosing (active metabolites) and carries high dependence and respiratory depression risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Profound sedation, anterograde amnesia, ataxia, falls, cognitive blunting. CRITICAL — Tolerance, physical dependence, and severe withdrawal seizures upon abrupt cessation.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "CRITICAL — Respiratory depression (especially if given rapidly IV or mixed with opioids).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Hypotension (mostly IV).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Anxiety / Muscle Spasm", + "val": "**PO** 2-10 mg **BD** to **QID**.", + "tags": [] + }, + { + "key": "Alcohol Withdrawal", + "val": "**PO** 10-20 mg q1-2h PRN using a symptom-triggered CIWA-Ar scale.", + "tags": [] + }, + { + "key": "Status Epilepticus", + "val": "**IV** 5-10 mg pushed slowly (2-5 mg/min). Max 20 mg.", + "tags": [] + }, + { + "key": "Elderly / Hepatic", + "val": "MANDATORY — Avoid or halve dose. Prefer Oxazepam or Lorazepam.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Valium, Antenex, Ducene", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (2 mg, 5 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (10 mg/2 mL) for **IV** use. Avoid IM (erratic absorption and painful).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4). High abuse potential.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute anxiety, muscle spasms, alcohol withdrawal, status epilepticus.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The gold standard for alcohol withdrawal due to 'auto-tapering' (long half-life prevents sudden withdrawal seizures).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe respiratory insufficiency, sleep apnea, Myasthenia Gravis.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "CRITICAL — Active metabolites require extensive hepatic clearance. Avoid in severe cirrhosis to prevent hepatic encephalopathy/coma.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C (Risk of 'Floppy Infant Syndrome').", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Diazepam pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Opioids, Barbiturates, Alcohol. Additive and synergistic CNS/respiratory depression. Major cause of overdose deaths.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — CYP3A4 and CYP2C19 inhibitors (e.g., Omeprazole, Cimetidine) significantly prolong half-life.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **SpO2** and **RR** if using IV. Assess for over-sedation and falls risk in all patients.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Auto-Taper", + "val": "Diazepam is preferred in alcohol withdrawal because you load the patient with a massive dose on day 1 and 2, and then simply stop. The 100+ hour half-life of the metabolites tapers the drug out of the body naturally over a week, preventing seizures without needing complex weaning schedules.", + "tags": [] + }, + { + "key": "The Vein Burn", + "val": "IV Diazepam is dissolved in propylene glycol. It burns fiercely when injected and causes severe thrombophlebitis. Always use a large vein and flush well.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Positive allosteric modulator (PAM) at the GABA-A receptor. Enhances the effect of GABA, increasing chloride influx and hyperpolarizing (sedating) the neuron.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 15-30 mins (Very fast due to high lipophilicity). **IV** 1-5 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "20-100 hours. The primary active metabolite (desmethyldiazepam) has a half-life up to 200 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DIAZEPAM-WGR ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Long-acting GABA-A PAM — Highly lipophilic, long-acting benzodiazepine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (2 mg, 5 mg). (Valium, Antenex, Ducene)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 2-10 mg **BD** to **QID**. Max varies entirely by indication (40 mg/day for anxiety, massive doses >100mg for acute alcohol withdrawal)." + }, + { + "label": "Key Indication Doses", + "value": "Anxiety / Muscle Spasm: **PO** 2-10 mg **BD** to **QID**. Alcohol Withdrawal: **PO** 10-20 mg q1-2h PRN using a symptom-triggered CIWA-Ar scale. Status Epilepticus: **IV** 5-10 mg pushed slowly (2-5 mg/min). Max 20 mg. Elderly / Hepatic: Avoid or halve dose. Prefer Oxazepam or Lorazepam." + }, + { + "label": "Best Uses", + "value": "Diazepam is a long-acting benzodiazepine for acute anxiety, seizures, and alcohol withdrawal, but accumulates with repeated dosing (active metabolites) and carries high dependence and respiratory depression risk." + }, + { + "label": "Avoid / Cautions", + "value": "Severe respiratory insufficiency, sleep apnea, Myasthenia Gravis. **Pregnancy** Category C (Risk of 'Floppy Infant Syndrome')." + }, + { + "label": "Key Risks", + "value": "Neurological: Profound sedation, anterograde amnesia, ataxia, falls, cognitive blunting. CRITICAL — Tolerance, physical dependence, and severe withdrawal seizures upon abrupt cessation. Respiratory: Respiratory depression (especially if given rapidly IV or mixed with opioids). Cardiovascular: Hypotension (mostly IV)." + }, + { + "label": "Key Interactions", + "value": "Opioids, Barbiturates, Alcohol. Additive and synergistic CNS/respiratory depression. Major cause of overdose deaths. CYP3A4 and CYP2C19 inhibitors (e.g., Omeprazole, Cimetidine) significantly prolong half-life." + }, + { + "label": "Monitoring", + "value": "Monitor **SpO2** and **RR** if using IV. Assess for over-sedation and falls risk in all patients. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Diazepam is preferred in alcohol withdrawal because you load the patient with a massive dose on day 1 and 2, and then simply stop. The 100+ hour half-life of the metabolites tapers the drug out of the body naturally over a week, preventing seizures without needing complex weaning schedules." + } + ] + }, + { + "slug": "lorazepam", + "name": "Lorazepam", + "class": "Benzodiazepine", + "subclass": "Short/Intermediate-acting", + "category": "Neurology - Sedatives & Hypnotics", + "accent": "#6366f1", + "tag": "BENZO", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "4 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10-20 h", + "cls": "", + "flag": "" + }, + { + "label": "Hepatic Safe", + "value": "L.O.T. DRUG", + "cls": "good", + "flag": "" + }, + { + "label": "Dependence", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Intermediate-acting benzodiazepine. Does not require hepatic phase 1 metabolism, making it highly predictable and incredibly safe for the elderly and those with liver failure.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 mg/day** (Usually given in 0.5 - 1 mg doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The drug of choice for acute seizures or severe agitation in patients with end-stage liver cirrhosis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Lorazepam is the preferred benzodiazepine in hepatic impairment and status epilepticus (no active metabolites), but causes significant sedation and respiratory depression, and is highly dependency-forming.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Sedation, amnesia, ataxia, dependence, withdrawal seizures.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "CRITICAL — Respiratory depression when combined with opioids or pushed too rapidly IV.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Anxiety / Agitation", + "val": "**PO** or **SL** 0.5 - 1 mg PRN. Max 4 mg/day.", + "tags": [] + }, + { + "key": "Status Epilepticus", + "val": "**IV** 4 mg slow push (2 mg/min).", + "tags": [] + }, + { + "key": "Alcohol Withdrawal (Hepatic Failure)", + "val": "**PO** 1-2 mg q2h PRN (replaces diazepam).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Ativan", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (1 mg, 2.5 mg). Can be dissolved sublingually.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** / **IM** use. (Unlike Diazepam, IM absorption is excellent and predictable).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute agitation, status epilepticus, short-term anxiety, alcohol withdrawal in hepatic impairment.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly versatile. Binds tightly to the receptor, providing longer clinical effect than its half-life suggests.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe respiratory failure, Myasthenia Gravis.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "SAFE — One of the 'L.O.T.' benzos (Lorazepam, Oxazepam, Temazepam) that do not require CYP450 oxidation. The safest options in liver disease.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "info", + "severity": "info", + "note": "Existing row describes this as a safer option in hepatic impairment; highlight as information only, not as a contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Opioids, Alcohol, Barbiturates (fatal respiratory depression).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **SpO2** and **RR** during IV use. High falls risk on the ward.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Sublingual Hack", + "val": "While not officially marked as sublingual, the 1mg and 2.5mg Ativan tablets dissolve rapidly under the tongue. This bypasses the gut and provides rapid relief for acute panic or agitation when an IV line isn't available.", + "tags": [] + }, + { + "key": "The Cirrhosis Savior", + "val": "If a patient with liver cirrhosis goes into alcohol withdrawal, giving them Diazepam will put them in a coma for a week. You MUST use Lorazepam or Oxazepam, which are cleared cleanly by conjugation.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Enhances GABA-A receptor action, increasing chloride channel opening.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins. **IV** 1-5 mins. **IM** 15-30 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10-20 hours. Undergoes Phase II glucuronidation directly (No active metabolites!).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - LORAZEPAM-WGR ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Short/Intermediate-acting — Intermediate-acting benzodiazepine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (1 mg, 2.5 mg). Can be dissolved sublingually. (Ativan)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** or **SL** 0.5 - 1 mg PRN. Max 4 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Acute Anxiety / Agitation: **PO** or **SL** 0.5 - 1 mg PRN. Max 4 mg/day. Status Epilepticus: **IV** 4 mg slow push (2 mg/min). Alcohol Withdrawal (Hepatic Failure): **PO** 1-2 mg q2h PRN (replaces diazepam)." + }, + { + "label": "Best Uses", + "value": "Lorazepam is the preferred benzodiazepine in hepatic impairment and status epilepticus (no active metabolites), but causes significant sedation and respiratory depression, and is highly dependency-forming." + }, + { + "label": "Avoid / Cautions", + "value": "Severe respiratory failure, Myasthenia Gravis." + }, + { + "label": "Key Risks", + "value": "Neurological: Sedation, amnesia, ataxia, dependence, withdrawal seizures. Respiratory: Respiratory depression when combined with opioids or pushed too rapidly IV." + }, + { + "label": "Key Interactions", + "value": "Opioids, Alcohol, Barbiturates (fatal respiratory depression)." + }, + { + "label": "Monitoring", + "value": "Monitor **SpO2** and **RR** during IV use. High falls risk on the ward. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "While not officially marked as sublingual, the 1mg and 2.5mg Ativan tablets dissolve rapidly under the tongue. This bypasses the gut and provides rapid relief for acute panic or agitation when an IV line isn't available." + } + ] + }, + { + "slug": "midazolam", + "name": "Midazolam", + "class": "Benzodiazepine", + "subclass": "Ultra-short acting", + "category": "Neurology - Sedatives & Hypnotics", + "accent": "#6366f1", + "tag": "BENZO", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1.5–2.5 h", + "cls": "warn", + "flag": "" + }, + { + "label": "Resp. Drop", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Amnesia", + "value": "PROFOUND", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-short acting, intensely potent benzodiazepine. Used almost exclusively for procedural sedation, acute seizure termination, and palliative end-of-life distress.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated strictly to clinical effect (sedation or seizure cessation).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "High risk of sudden respiratory arrest. Must never be pushed IV outside of a monitored resuscitation setting (ED/ICU/OT).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Midazolam is the standard short-acting benzodiazepine for procedural sedation and acute seizures (buccal/IM), but causes potent respiratory depression especially when combined with opioids.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory", + "val": "CRITICAL — Apnoea, profound respiratory depression, airway obstruction (loss of pharyngeal tone).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Hypotension, vasodilation.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Profound anterograde amnesia (desired for procedures, dangerous otherwise), paradoxical agitation (especially in kids/elderly).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Older adults need close monitoring for paradoxical agitation, oversedation, and falls." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Status Epilepticus", + "val": "**IV** or **IM** 5-10 mg STAT. OR **Buccal** 10 mg (Highly effective in pediatrics and community).", + "tags": [] + }, + { + "key": "Procedural Sedation", + "val": "**IV** 1-2 mg slowly. Titrate to effect. (Requires dedicated airway practitioner).", + "tags": [] + }, + { + "key": "Palliative Agitation", + "val": "**SC** 2.5-5 mg PRN or via 24h continuous syringe driver.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Hypnovel", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (5 mg/1 mL, 15 mg/3 mL) for **IV**, **IM**, **SC**, or **Buccal** administration.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply / Palliative care PBS.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Status epilepticus, procedural sedation/amnesia, severe palliative agitation.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "The fastest, strongest, shortest-acting benzo. The ultimate chemical restraint for immediate life threats.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Unmonitored environments without airway equipment.", + "tags": [] + }, + { + "key": "Elderly & Frail", + "val": "CAUTION — Massively increased sensitivity. Reduce doses by 50% or more. Give 0.5-1 mg increments.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Older adults and frail patients require lower initial doses and slow titration." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Fentanyl / Morphine. The combination of Midazolam + Fentanyl is synergistic for procedural sedation but synergistic for fatal apnoea.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong **CYP3A4** inhibitors (Clarithromycin) massively prolong the coma.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Continuous **SpO2**, **RR**, and **BP**. Resuscitation equipment (bag-valve-mask, suction, Flumazenil) MUST be at the bedside.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Buccal Rescue", + "val": "In an actively seizing patient, gaining IV access is nearly impossible and IM injections take 15 minutes to work. Drawing up the IV ampoule into a syringe and squirting it into the buccal space (between cheek and gum) provides rapid, massive absorption straight into the brain.", + "tags": [] + }, + { + "key": "Paradoxical Rage", + "val": "In some elderly or pediatric patients, midazolam removes frontal lobe inhibition, causing violent, screaming agitation instead of sedation. If this happens, stop giving midazolam and switch to an antipsychotic (Haloperidol/Droperidol).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent GABA-A receptor PAM. Highly lipid-soluble at physiological pH, rapidly crossing the blood-brain barrier.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 1-2 mins. **IM** 5 mins. **Buccal** 5-10 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "15-60 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1.5 - 2.5 hours. Metabolised hepatically by CYP3A4 into an active but weak metabolite.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - MIDAZOLAM VIATRIS ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Ultra-short acting — Ultra-short acting, intensely potent benzodiazepine." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (5 mg/1 mL, 15 mg/3 mL) for **IV**, **IM**, **SC**, or **Buccal** administration. (Hypnovel)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** or **IM** 5-10 mg STAT. OR **Buccal** 10 mg (Highly effective in pediatrics and community). Titrated strictly to clinical effect (sedation or seizure cessation)." + }, + { + "label": "Key Indication Doses", + "value": "Status Epilepticus: **IV** or **IM** 5-10 mg STAT. OR **Buccal** 10 mg (Highly effective in pediatrics and community). Procedural Sedation: **IV** 1-2 mg slowly. Titrate to effect. (Requires dedicated airway practitioner). Palliative Agitation: **SC** 2.5-5 mg PRN or via 24h continuous syringe driver." + }, + { + "label": "Best Uses", + "value": "Midazolam is the standard short-acting benzodiazepine for procedural sedation and acute seizures (buccal/IM), but causes potent respiratory depression especially when combined with opioids." + }, + { + "label": "Avoid / Cautions", + "value": "Unmonitored environments without airway equipment." + }, + { + "label": "Key Risks", + "value": "Respiratory: Apnoea, profound respiratory depression, airway obstruction (loss of pharyngeal tone). Cardiovascular: Hypotension, vasodilation. Neurological: Profound anterograde amnesia (desired for procedures, dangerous otherwise), paradoxical agitation (especially in kids/elderly)." + }, + { + "label": "Key Interactions", + "value": "Fentanyl / Morphine. The combination of Midazolam + Fentanyl is synergistic for procedural sedation but synergistic for fatal apnoea. Strong **CYP3A4** inhibitors (Clarithromycin) massively prolong the coma." + }, + { + "label": "Monitoring", + "value": "Continuous **SpO2**, **RR**, and **BP**. Resuscitation equipment (bag-valve-mask, suction, Flumazenil) MUST be at the bedside." + }, + { + "label": "Clinical Pearl", + "value": "In an actively seizing patient, gaining IV access is nearly impossible and IM injections take 15 minutes to work. Drawing up the IV ampoule into a syringe and squirting it into the buccal space (between cheek and gum) provides rapid, massive absorption straight into the brain." + } + ] + }, + { + "slug": "nitrazepam", + "name": "Nitrazepam", + "class": "Benzodiazepine", + "subclass": "Long-acting hypnotic", + "category": "Neurology - Sedatives & Hypnotics", + "accent": "#6366f1", + "tag": "BENZO", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "15-38 h", + "cls": "", + "flag": "" + }, + { + "label": "Hangover", + "value": "SEVERE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Elderly", + "value": "AVOID", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Long-acting benzodiazepine hypnotic. Induces sleep effectively but possesses an excessively long half-life, causing a massive, functionally impairing next-day hangover.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day** (Normally 5 mg NOCTE).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly toxic in the elderly. Will accumulate over successive nights, leading to profound daytime sedation, delirium, and fractured hips.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Nitrazepam is a long-acting benzodiazepine hypnotic, but accumulates in elderly causing excessive daytime sedation and falls, and has been largely replaced by shorter-acting agents.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Next-day hangover (cognitive blunting, lethargy, ataxia). HIGH — Tolerance, dependence, withdrawal seizures if stopped abruptly after chronic use.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "HIGH — Exacerbates obstructive sleep apnea (OSA) and respiratory failure.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Insomnia", + "val": "**PO** 5-10 mg **NOCTE** (Take 30-60 mins before bed).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "CRITICAL — Avoid entirely. If forced, max 2.5 - 5 mg. (Temazepam is vastly superior).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Mogadon, Alodorm", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Short-term treatment of severe insomnia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Infantile spasms (West syndrome - rare pediatric epilepsy use).", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Largely obsolete for insomnia. Outperformed by Temazepam (short half-life) or Z-drugs for safety and hangover profiles.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe respiratory failure, Myasthenia Gravis, severe hepatic impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Elderly", + "val": "CRITICAL — Avoid routine use in older/frail patients because prolonged sedation, confusion, unsteadiness and falls are common. If unavoidable, use the lowest dose for the shortest duration and review frequently.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Nitrazepam is long-acting and substantially increases sedation, confusion, unsteadiness and falls in older/frail patients." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Opioids, Alcohol (Fatal respiratory arrest).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — CYP3A4 inhibitors (Clarithromycin, Azoles) prolong half-life further.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Advise the patient strictly not to drive the morning after taking Nitrazepam. Their reaction times will be identical to a drunk driver.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Accumulation Trap", + "val": "If a patient takes 5mg every night, because the half-life is 30 hours, they haven't cleared yesterday's dose before they take today's dose. By Day 5, they functionally have 15mg in their system and are comatose during the day. Avoid for sequential nightly use.", + "tags": [] + }, + { + "key": "The 'Mogadon' Name", + "val": "Mogadon was heavily prescribed in the 1980s. Many older patients are addicted to it and will demand it. You must actively cross-taper them to safer alternatives if admitted to the ward.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "GABA-A PAM. Enhances inhibitory GABA transmission, inducing sedation and muscle relaxation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "15-38 hours (Hepatically metabolised. Accumulates heavily with nightly use).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - MOGADON/ALODORM nitrazepam ARTG, PI/CMI, and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Long-acting hypnotic — Long-acting benzodiazepine hypnotic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg). (Mogadon, Alodorm)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5-10 mg **NOCTE** (Take 30-60 mins before bed). Max **10 mg/day** (Normally 5 mg NOCTE)." + }, + { + "label": "Key Indication Doses", + "value": "Severe Insomnia: **PO** 5-10 mg **NOCTE** (Take 30-60 mins before bed). Elderly / Frail: Avoid entirely. If forced, max 2.5 - 5 mg. (Temazepam is vastly superior)." + }, + { + "label": "Best Uses", + "value": "Nitrazepam is a long-acting benzodiazepine hypnotic, but accumulates in elderly causing excessive daytime sedation and falls, and has been largely replaced by shorter-acting agents." + }, + { + "label": "Avoid / Cautions", + "value": "Severe respiratory failure, Myasthenia Gravis, severe hepatic impairment." + }, + { + "label": "Key Risks", + "value": "Neurological: Next-day hangover (cognitive blunting, lethargy, ataxia). HIGH — Tolerance, dependence, withdrawal seizures if stopped abruptly after chronic use. Respiratory: Exacerbates obstructive sleep apnea (OSA) and respiratory failure." + }, + { + "label": "Key Interactions", + "value": "Opioids, Alcohol (Fatal respiratory arrest). CYP3A4 inhibitors (Clarithromycin, Azoles) prolong half-life further." + }, + { + "label": "Monitoring", + "value": "Advise the patient strictly not to drive the morning after taking Nitrazepam. Their reaction times will be identical to a drunk driver." + }, + { + "label": "Clinical Pearl", + "value": "If a patient takes 5mg every night, because the half-life is 30 hours, they haven't cleared yesterday's dose before they take today's dose. By Day 5, they functionally have 15mg in their system and are comatose during the day. Avoid for sequential nightly use." + } + ] + }, + { + "slug": "oxazepam", + "name": "Oxazepam", + "class": "Benzodiazepine", + "subclass": "Short-acting", + "category": "Neurology - Sedatives & Hypnotics", + "accent": "#6366f1", + "tag": "BENZO", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "120 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4-15 h", + "cls": "", + "flag": "" + }, + { + "label": "Hepatic Safe", + "value": "L.O.T. DRUG", + "cls": "good", + "flag": "" + }, + { + "label": "Onset", + "value": "SLOW", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Short-acting benzodiazepine. Does not require hepatic Phase 1 metabolism. It is the safest, most predictable oral benzo for the elderly and patients with liver cirrhosis.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **120 mg/day** (Typically 15-30 mg per dose).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Has a very slow onset of action. It produces zero 'rush' or euphoria, making it excellent for preventing abuse but terrible for acute panic attacks.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Oxazepam is a short-acting benzodiazepine preferred in elderly and hepatic impairment (no active metabolites), but has slower onset than other BZDs and still carries dependence risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "MODERATE — Sedation, falls risk, ataxia, confusion. (Much lower risk of multi-day 'hangover' compared to diazepam due to lack of metabolites).", + "tags": [] + }, + { + "key": "Respiratory", + "val": "MODERATE — Respiratory depression (if mixed with opioids).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Anxiety", + "val": "**PO** 15-30 mg **TDS** to **QID**.", + "tags": [] + }, + { + "key": "Insomnia", + "val": "**PO** 15-30 mg **NOCTE** (Take 1 hour before bed due to slow onset).", + "tags": [] + }, + { + "key": "Alcohol Withdrawal (in Cirrhosis)", + "val": "**PO** 15-30 mg q2h PRN based on CIWA-Ar scale.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Start at 7.5 mg (Half a 15mg tablet).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Serepax, Murelax", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (15 mg, 30 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Short-term anxiety, insomnia, alcohol withdrawal in hepatic impairment.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The workhorse anxiolytic for the geriatric ward. Displaces Diazepam entirely in patients > 65 years.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe respiratory failure, Myasthenia Gravis.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "SAFE — The drug of choice for anxiety/withdrawal in severe liver failure (alongside Lorazepam).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "info", + "severity": "info", + "note": "Existing row describes this as a safer option in hepatic impairment; highlight as information only, not as a contraindication." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Oxazepam pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Opioids, Alcohol (Fatal respiratory arrest).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "LOW — Impervious to CYP450 drug interactions. Safe to mix with Clarithromycin or Amiodarone.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Assess falls risk in the elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Older adults require falls-risk and sedation monitoring with benzodiazepines." + } + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Abuse Deterrent", + "val": "Addicts rarely seek Oxazepam. Because it is highly water-soluble, it trickles into the brain slowly over 2 hours. It provides zero dopamine 'rush' or 'hit'. It simply smooths out the anxiety smoothly and safely.", + "tags": [] + }, + { + "key": "The Cirrhosis Rescue", + "val": "If an alcoholic with yellow eyes, ascites, and liver cirrhosis goes into DTs (Delirium Tremens), Diazepam will kill them or put them in a coma for a month. You MUST use Oxazepam.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Positive allosteric modulator of GABA-A. Highly water-soluble compared to diazepam, meaning it crosses the blood-brain barrier slowly.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 60-120 mins (Very slow).", + "tags": [] + }, + { + "key": "Duration", + "val": "6-8 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "4-15 hours. Glucuronidated directly (No active metabolites).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - SEREPAX ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Short-acting — Short-acting benzodiazepine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (15 mg, 30 mg). (Serepax, Murelax)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 15-30 mg **TDS** to **QID**. Max **120 mg/day** (Typically 15-30 mg per dose)." + }, + { + "label": "Key Indication Doses", + "value": "Anxiety: **PO** 15-30 mg **TDS** to **QID**. Insomnia: **PO** 15-30 mg **NOCTE** (Take 1 hour before bed due to slow onset). Alcohol Withdrawal (in Cirrhosis): **PO** 15-30 mg q2h PRN based on CIWA-Ar scale. Elderly / Frail: Start at 7.5 mg (Half a 15mg tablet)." + }, + { + "label": "Best Uses", + "value": "Oxazepam is a short-acting benzodiazepine preferred in elderly and hepatic impairment (no active metabolites), but has slower onset than other BZDs and still carries dependence risk." + }, + { + "label": "Avoid / Cautions", + "value": "Severe respiratory failure, Myasthenia Gravis. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Sedation, falls risk, ataxia, confusion. (Much lower risk of multi-day 'hangover' compared to diazepam due to lack of metabolites). Respiratory: Respiratory depression (if mixed with opioids)." + }, + { + "label": "Key Interactions", + "value": "Opioids, Alcohol (Fatal respiratory arrest). Impervious to CYP450 drug interactions. Safe to mix with Clarithromycin or Amiodarone." + }, + { + "label": "Monitoring", + "value": "Assess falls risk in the elderly. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Addicts rarely seek Oxazepam. Because it is highly water-soluble, it trickles into the brain slowly over 2 hours. It provides zero dopamine 'rush' or 'hit'. It simply smooths out the anxiety smoothly and safely." + } + ] + }, + { + "slug": "temazepam", + "name": "Temazepam", + "class": "Benzodiazepine", + "subclass": "Short-acting hypnotic", + "category": "Neurology - Sedatives & Hypnotics", + "accent": "#6366f1", + "tag": "BENZO", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "30 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "8-15 h", + "cls": "", + "flag": "" + }, + { + "label": "Hepatic Safe", + "value": "L.O.T. DRUG", + "cls": "good", + "flag": "" + }, + { + "label": "Hangover", + "value": "LOW RISK", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Short-acting benzodiazepine hypnotic. Rapidly absorbed, directly conjugated, and cleared by morning. The quintessential sleeping pill for ward patients.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **30 mg/day** (Normally 10 mg is sufficient).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Tolerance builds within 2 weeks. Do not prescribe chronically.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Temazepam is a short-acting benzodiazepine hypnotic for insomnia, but carries high abuse potential (Schedule 8 in some jurisdictions) and should only be used short-term.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "MODERATE — Sedation, amnesia, midnight confusion/falls (especially if the patient gets up to urinate). Tolerance and dependence with chronic use.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "MODERATE — Can exacerbate obstructive sleep apnea (OSA) by relaxing pharyngeal muscles.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Insomnia", + "val": "**PO** 10-20 mg **NOCTE** (Take 30 mins before bed).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Max 10 mg **NOCTE**. (Higher doses risk midnight falls).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Normison, Temaze", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Short-term management of severe insomnia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Excellent for transient ward-based insomnia where the goal is to induce sleep without leaving the patient drowsy the next day.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe respiratory failure, severe OSA, Myasthenia Gravis.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "SAFE — The 'T' in the L.O.T. benzos (Lorazepam, Oxazepam, Temazepam). Very safe in cirrhosis.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "info", + "severity": "info", + "note": "Existing row describes this as a safer option in hepatic impairment; highlight as information only, not as a contraindication." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Temazepam pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Opioids, Alcohol (Fatal respiratory arrest).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "LOW — No significant CYP interactions.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the elderly patient has a urinal or commode next to the bed. If they walk to the bathroom at 2 AM under the influence of Temazepam, they will fall and break their hip.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Older adults require falls-risk and sedation monitoring with hypnotics." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Gel Cap Ban", + "val": "Historically, Temazepam came in liquid-filled gel capsules. Heroin addicts discovered they could melt the gel and inject it, causing catastrophic limb gangrene and amputations. The gel caps were globally banned and it is now strictly tablets only.", + "tags": [] + }, + { + "key": "The Hangover Profile", + "val": "Because it has no active metabolites and an 8-hour duration, a 10mg dose at 10 PM is entirely cleared from the brain by 7 AM. The patient wakes up refreshed, unlike Diazepam or Nitrazepam which cause all-day grogginess.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "GABA-A PAM. Highly lipophilic (rapid brain entry for sleep onset), but rapidly redistributed and cleared.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "6-8 h (Perfect length for a night's sleep).", + "tags": [] + }, + { + "key": "Half-life", + "val": "8-15 hours. Glucuronidated directly (No active metabolites).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TEMAZE ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Short-acting hypnotic — Short-acting benzodiazepine hypnotic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg). (Normison, Temaze)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10-20 mg **NOCTE** (Take 30 mins before bed). Max **30 mg/day** (Normally 10 mg is sufficient)." + }, + { + "label": "Key Indication Doses", + "value": "Insomnia: **PO** 10-20 mg **NOCTE** (Take 30 mins before bed). Elderly / Frail: Max 10 mg **NOCTE**. (Higher doses risk midnight falls)." + }, + { + "label": "Best Uses", + "value": "Temazepam is a short-acting benzodiazepine hypnotic for insomnia, but carries high abuse potential (Schedule 8 in some jurisdictions) and should only be used short-term." + }, + { + "label": "Avoid / Cautions", + "value": "Severe respiratory failure, severe OSA, Myasthenia Gravis. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Sedation, amnesia, midnight confusion/falls (especially if the patient gets up to urinate). Tolerance and dependence with chronic use. Respiratory: Can exacerbate obstructive sleep apnea (OSA) by relaxing pharyngeal muscles." + }, + { + "label": "Key Interactions", + "value": "Opioids, Alcohol (Fatal respiratory arrest). No significant CYP interactions." + }, + { + "label": "Monitoring", + "value": "Ensure the elderly patient has a urinal or commode next to the bed. If they walk to the bathroom at 2 AM under the influence of Temazepam, they will fall and break their hip." + }, + { + "label": "Clinical Pearl", + "value": "Historically, Temazepam came in liquid-filled gel capsules. Heroin addicts discovered they could melt the gel and inject it, causing catastrophic limb gangrene and amputations. The gel caps were globally banned and it is now strictly tablets only." + } + ] + }, + { + "slug": "zolpidem", + "name": "Zolpidem", + "class": "Sedative", + "subclass": "Imidazopyridine / Z-Drug", + "category": "Neurology - Sedatives & Hypnotics", + "accent": "#6366f1", + "tag": "HYPNOTIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2.5 h", + "cls": "", + "flag": "" + }, + { + "label": "Parasomnias", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Sleep Onset", + "value": "RAPID", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Non-benzodiazepine 'Z-Drug' hypnotic. Highly selective for the sleep-inducing subunit of the GABA receptor. Excellent for putting patients to sleep, but terrible at keeping them asleep.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day** (Adults) or **5 mg/day** (Elderly / Females).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Notorious for causing bizarre, complex sleep behaviors (sleep-walking, sleep-eating, sleep-driving) with zero memory of the event.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Zolpidem is a Z-drug hypnotic for short-term insomnia management, but causes complex sleep behaviours (sleep-driving, sleep-eating) and should only be used for 2-4 weeks maximum.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Complex parasomnias (sleepwalking, cooking, or driving while entirely asleep with full amnesia). HIGH — Next-day drowsiness (especially in women/elderly).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Psychiatric", + "val": "MODERATE — Hallucinations, worsened depression, suicidal ideation.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "MODERATE — Can worsen severe Obstructive Sleep Apnea (OSA).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Insomnia (Sleep Onset)", + "val": "**PO** 10 mg STAT immediately before bed. Do not re-dose in the middle of the night.", + "tags": [] + }, + { + "key": "Elderly / Females / Hepatic", + "val": "MANDATORY — Max **5 mg/day**. Females clear the drug much slower than males, leaving them impaired the next morning if given 10mg.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Stilnox, Somidem", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg). CR Tablets (12.5 mg - Stilnox CR).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). S4 (but frequently monitored like an S8).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Short-term treatment of insomnia (specifically difficulty falling asleep).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Step 2 for ward insomnia (after melatonin or simple measures). Maximum duration of use should be 4 weeks.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of complex sleep behaviors after taking Z-drugs, severe respiratory failure, Myasthenia Gravis.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Zolpidem pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Alcohol (Massively increases the risk of sleepwalking/amnesia and respiratory depression).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — CYP3A4 inhibitors (increase levels) and inducers (Rifampicin makes Zolpidem useless).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the patient has at least 8 hours dedicated to sleep before taking the pill to prevent next-day impairment. Do not take with a heavy meal (delays absorption).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Gender Divide", + "val": "The FDA and TGA mandate a 5mg starting dose for women because they clear Zolpidem significantly slower than men. A 10mg dose in a woman often leaves blood levels high enough the next morning to cause car crashes.", + "tags": [] + }, + { + "key": "The Hallucination Trap", + "val": "If a patient takes Zolpidem and fights the sleep to stay awake and watch TV, the drug causes intense, vivid, and often frightening visual hallucinations. They must take it *in bed*.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds highly selectively to the alpha-1 subunit of the GABA-A receptor. Induces sleep without significantly altering sleep architecture (maintains deep sleep better than benzos). Has very weak anti-anxiety or muscle-relaxant properties.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 15-30 mins (Must be in bed when taking it).", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2.5 hours. Cleared by CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ZOLPIDEM-WGR ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Imidazopyridine / Z-Drug — Non-benzodiazepine 'Z-Drug' hypnotic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg). CR Tablets (12.5 mg - Stilnox CR). (Stilnox, Somidem)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10 mg STAT immediately before bed. Do not re-dose in the middle of the night. Max **10 mg/day** (Adults) or **5 mg/day** (Elderly / Females)." + }, + { + "label": "Key Indication Doses", + "value": "Insomnia (Sleep Onset): **PO** 10 mg STAT immediately before bed. Do not re-dose in the middle of the night. Elderly / Females / Hepatic: Max **5 mg/day**. Females clear the drug much slower than males, leaving them impaired the next morning if given 10mg." + }, + { + "label": "Best Uses", + "value": "Zolpidem is a Z-drug hypnotic for short-term insomnia management, but causes complex sleep behaviours (sleep-driving, sleep-eating) and should only be used for 2-4 weeks maximum." + }, + { + "label": "Avoid / Cautions", + "value": "History of complex sleep behaviors after taking Z-drugs, severe respiratory failure, Myasthenia Gravis. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Neurological: Complex parasomnias (sleepwalking, cooking, or driving while entirely asleep with full amnesia). HIGH — Next-day drowsiness (especially in women/elderly). Psychiatric: Hallucinations, worsened depression, suicidal ideation. Respiratory: Can worsen severe Obstructive Sleep Apnea (OSA)." + }, + { + "label": "Key Interactions", + "value": "Alcohol (Massively increases the risk of sleepwalking/amnesia and respiratory depression). CYP3A4 inhibitors (increase levels) and inducers (Rifampicin makes Zolpidem useless)." + }, + { + "label": "Monitoring", + "value": "Ensure the patient has at least 8 hours dedicated to sleep before taking the pill to prevent next-day impairment. Do not take with a heavy meal (delays absorption)." + }, + { + "label": "Clinical Pearl", + "value": "The FDA and TGA mandate a 5mg starting dose for women because they clear Zolpidem significantly slower than men. A 10mg dose in a woman often leaves blood levels high enough the next morning to cause car crashes." + } + ] + }, + { + "slug": "zopiclone", + "name": "Zopiclone", + "class": "Sedative", + "subclass": "Cyclopyrrolone / Z-Drug", + "category": "Neurology - Sedatives & Hypnotics", + "accent": "#6366f1", + "tag": "HYPNOTIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "7.5 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5 h", + "cls": "", + "flag": "" + }, + { + "label": "Bitter Taste", + "value": "SEVERE", + "cls": "warn", + "flag": "" + }, + { + "label": "Sleep Maint.", + "value": "BETTER", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Non-benzodiazepine 'Z-Drug' hypnotic. Longer half-life than Zolpidem, making it better for patients who wake up at 3 AM, but causes a relentless metallic taste in the mouth.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **7.5 mg/day** (Adults) or **3.75 mg/day** (Elderly/Hepatic).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Has a longer duration than Zolpidem, so next-day hangover and falls risk in the elderly is significantly higher.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Zopiclone is a Z-drug hypnotic for short-term insomnia with rapid onset, but causes metallic taste and next-day impairment, and carries the same dependence risk as benzodiazepines.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Dysgeusia (a severe, lingering metallic/bitter taste in the mouth the entire next day. Affects up to 20% of patients).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Morning hangover, dizziness, ataxia. MODERATE — Parasomnias (sleepwalking), but slightly less common than Zolpidem.", + "tags": [] + }, + { + "key": "Psychiatric", + "val": "MODERATE — Depression, confusion in the elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Insomnia (Onset & Maintenance)", + "val": "**PO** 7.5 mg STAT immediately before bed.", + "tags": [] + }, + { + "key": "Elderly / Hepatic / Frail", + "val": "MANDATORY — Max **3.75 mg/day** (Half a tablet).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Imovane, Imrest", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (7.5 mg). Scored to snap into 3.75 mg.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Short-term treatment of insomnia (difficulty falling asleep and early morning awakening).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Preferred over Zolpidem if the primary issue is sleep *maintenance* rather than just sleep onset.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe respiratory failure, Myasthenia Gravis, severe hepatic impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Zopiclone pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Alcohol and other CNS depressants (Synergistic respiratory depression).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — CYP3A4 inhibitors (e.g., Erythromycin) double blood levels, causing severe next-day sedation.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn the patient about the bitter taste. Do not let them take it at 2 AM when they wake up, or they will be profoundly impaired the next morning.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Taste Secret", + "val": "The bitter taste is not from the pill on the tongue; it is secreted into the saliva from the bloodstream. Water and brushing teeth will not fix it. It only fades when the drug leaves the body.", + "tags": [] + }, + { + "key": "The Rebound Trap", + "val": "Using Zopiclone for more than 2-4 weeks builds tolerance. When stopped, the patient will suffer 'rebound insomnia' worse than their baseline. Use intermittently (e.g., 3 nights a week) if possible.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to the GABA-A receptor complex at a site distinct from benzodiazepines. Enhances GABA transmission, inducing sleep.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "6-8 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5 hours (Metabolised by CYP3A4).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - IPCA-ZOPICLONE ARTG/CMI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Cyclopyrrolone / Z-Drug — Non-benzodiazepine 'Z-Drug' hypnotic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (7.5 mg). Scored to snap into 3.75 mg. (Imovane, Imrest)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 7.5 mg STAT immediately before bed. Max **7.5 mg/day** (Adults) or **3.75 mg/day** (Elderly/Hepatic)." + }, + { + "label": "Key Indication Doses", + "value": "Insomnia (Onset & Maintenance): **PO** 7.5 mg STAT immediately before bed. Elderly / Hepatic / Frail: Max **3.75 mg/day** (Half a tablet)." + }, + { + "label": "Best Uses", + "value": "Zopiclone is a Z-drug hypnotic for short-term insomnia with rapid onset, but causes metallic taste and next-day impairment, and carries the same dependence risk as benzodiazepines." + }, + { + "label": "Avoid / Cautions", + "value": "Severe respiratory failure, Myasthenia Gravis, severe hepatic impairment. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Dysgeusia (a severe, lingering metallic/bitter taste in the mouth the entire next day. Affects up to 20% of patients). Neurological: Morning hangover, dizziness, ataxia. MODERATE — Parasomnias (sleepwalking), but slightly less common than Zolpidem. Psychiatric: Depression, confusion in the elderly." + }, + { + "label": "Key Interactions", + "value": "Alcohol and other CNS depressants (Synergistic respiratory depression). CYP3A4 inhibitors (e.g., Erythromycin) double blood levels, causing severe next-day sedation." + }, + { + "label": "Monitoring", + "value": "Warn the patient about the bitter taste. Do not let them take it at 2 AM when they wake up, or they will be profoundly impaired the next morning." + }, + { + "label": "Clinical Pearl", + "value": "The bitter taste is not from the pill on the tongue; it is secreted into the saliva from the bloodstream. Water and brushing teeth will not fix it. It only fades when the drug leaves the body." + } + ] + }, + { + "slug": "atomoxetine", + "name": "Atomoxetine", + "class": "ADHD", + "subclass": "SNRI (Non-stimulant)", + "category": "Psychiatry - ADHD & Stimulants", + "accent": "#d97706", + "tag": "NON-STIMULANT", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "100 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5-24 h", + "cls": "", + "flag": "" + }, + { + "label": "Hepatotoxicity", + "value": "RARE RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Onset", + "value": "2-4 WEEKS", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Non-stimulant Noradrenaline Reuptake Inhibitor (NRI). Used for ADHD. Zero abuse potential. Highly effective but takes weeks to work, unlike instant stimulants.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **100 mg/day** (or 1.2 mg/kg/day in children).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Carries a rare black box warning for severe hepatotoxicity and increased suicidal ideation in children.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Atomoxetine is a non-stimulant option for ADHD without abuse potential, but takes 4-6 weeks for full effect and carries a rare risk of suicidal ideation in young people.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Hepatic", + "val": "CRITICAL — Severe idiosyncratic hepatotoxicity/liver failure (rare, but potentially fatal).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "monitor", + "severity": "caution", + "note": "Atomoxetine hepatic-risk rows should trigger liver-safety monitoring and clinical review." + } + }, + { + "key": "Psychiatric", + "val": "HIGH — Increased suicidal ideation in children/adolescents during the first month. Somnolence, fatigue.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Paediatric atomoxetine use requires monitoring for suicidal ideation, especially early in treatment." + } + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Tachycardia, hypertension (due to noradrenaline boost).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, vomiting, severe anorexia/weight loss.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "ADHD (Adults & Children > 70kg)", + "val": "Start **PO** 40 mg **OD** (morning). Titrate after 3 days to target 80 mg/day. Max 100 mg/day.", + "tags": [] + }, + { + "key": "ADHD (Children < 70kg)", + "val": "Start **PO** 0.5 mg/kg **OD**. Target 1.2 mg/kg/day.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "MANDATORY — Halve the dose in moderate hepatic impairment. Avoid in severe.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Strattera", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (10, 18, 25, 40, 60, 80, 100 mg). Do NOT open the capsule (powder is a severe ocular irritant).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Unrestricted S4 (Not an S8 controlled drug).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Attention Deficit Hyperactivity Disorder (ADHD) in children, adolescents, and adults.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The drug of choice for ADHD patients who have a history of substance abuse, severe anxiety/tics (which stimulants worsen), or those who cannot tolerate the stimulant 'crash'.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent MAOI use, narrow-angle glaucoma, severe cardiovascular disease, pheochromocytoma.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Atomoxetine pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong **CYP2D6** inhibitors (Fluoxetine, Paroxetine) massively spike Atomoxetine levels. Max dose must be capped at 80 mg/day (or much lower in children) if combined.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs (Fatal hypertensive crisis).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn parents/patients to stop the drug and present to ED instantly if yellow eyes, dark urine, or severe right-upper quadrant pain develops (Liver failure).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "monitor", + "severity": "caution", + "note": "Existing row asks patients to stop and seek urgent care for liver-failure symptoms; highlight as hepatic safety monitoring." + } + }, + { + "key": "Laboratory", + "val": "Baseline **BP**, **HR**, **Weight**, and Height (in kids).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Expectation Gap", + "val": "Patients who switch from Dexamphetamine to Atomoxetine often complain 'it does nothing'. You must counsel them that stimulants work in 30 minutes, but Atomoxetine takes 4 weeks to kick in. They must be patient.", + "tags": [] + }, + { + "key": "The 24-Hour Cover", + "val": "Because of its steady mechanism, it provides smooth, 24-hour ADHD symptom control, preventing the horrible evening behavioral crashes seen when Ritalin wears off in children.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Highly selective inhibitor of the pre-synaptic noradrenaline transporter (NET). Increases noradrenaline and dopamine specifically in the prefrontal cortex (improving focus/impulse control) without spiking dopamine in the striatum (zero euphoria/addiction).", + "tags": [] + }, + { + "key": "Onset", + "val": "2-4 WEEKS (Acts like an antidepressant, requires neuroplastic changes).", + "tags": [] + }, + { + "key": "Half-life", + "val": "5 hours (Extensive metabolizers) up to 24 hours (Poor metabolizers). Heavily dependent on CYP2D6.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ATOMOXETINE SANDOZ ARTG/PI and PBS search checked 2026-05-10 for ADHD/stimulant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SNRI (Non-stimulant) — Non-stimulant Noradrenaline Reuptake Inhibitor (NRI)." + }, + { + "label": "Route / Formulation", + "value": "Capsules (10, 18, 25, 40, 60, 80, 100 mg). Do NOT open the capsule (powder is a severe ocular irritant). (Strattera)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 40 mg **OD** (morning). Titrate after 3 days to target 80 mg/day. Max 100 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "ADHD (Adults & Children > 70kg): Start **PO** 40 mg **OD** (morning). Titrate after 3 days to target 80 mg/day. Max 100 mg/day. ADHD (Children < 70kg): Start **PO** 0.5 mg/kg **OD**. Target 1.2 mg/kg/day. Hepatic Impairment: Halve the dose in moderate hepatic impairment. Avoid in severe." + }, + { + "label": "Best Uses", + "value": "Atomoxetine is a non-stimulant option for ADHD without abuse potential, but takes 4-6 weeks for full effect and carries a rare risk of suicidal ideation in young people." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent MAOI use, narrow-angle glaucoma, severe cardiovascular disease, pheochromocytoma. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Hepatic: Severe idiosyncratic hepatotoxicity/liver failure (rare, but potentially fatal). Psychiatric: Increased suicidal ideation in children/adolescents during the first month. Somnolence, fatigue. Cardiovascular: Tachycardia, hypertension (due to noradrenaline boost). Gastrointestinal: Nausea, vomiting, severe anorexia/weight loss." + }, + { + "label": "Key Interactions", + "value": "Strong **CYP2D6** inhibitors (Fluoxetine, Paroxetine) massively spike Atomoxetine levels. Max dose must be capped at 80 mg/day (or much lower in children) if combined. MAOIs (Fatal hypertensive crisis)." + }, + { + "label": "Monitoring", + "value": "Warn parents/patients to stop the drug and present to ED instantly if yellow eyes, dark urine, or severe right-upper quadrant pain develops (Liver failure). Baseline **BP**, **HR**, **Weight**, and Height (in kids)." + }, + { + "label": "Clinical Pearl", + "value": "Patients who switch from Dexamphetamine to Atomoxetine often complain 'it does nothing'. You must counsel them that stimulants work in 30 minutes, but Atomoxetine takes 4 weeks to kick in. They must be patient." + } + ] + }, + { + "slug": "dexamfetamine", + "name": "Dexamfetamine", + "class": "ADHD", + "subclass": "CNS Stimulant", + "category": "Psychiatry - ADHD & Stimulants", + "accent": "#d97706", + "tag": "S8 STIMULANT", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "40 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10 h", + "cls": "", + "flag": "" + }, + { + "label": "Misuse Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Appetite Loss", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent, pure dextro-isomer of amphetamine. Releases massive stores of dopamine and noradrenaline. The highest abuse potential of the ADHD medications.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **40 mg/day** (State specialist guidelines may permit higher, e.g., 60 mg/day).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Immediate-release formulation with intense euphoric 'rush' potential. Strongly heavily regulated.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dexamfetamine is a potent stimulant for ADHD and narcolepsy, but is a Schedule 8 drug with high abuse potential requiring cardiovascular monitoring and strict prescribing controls.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Extreme abuse, addiction, and diversion risk. HIGH — Insomnia, anxiety, amphetamine psychosis (hallucinations/paranoia), tics.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Tachycardia, hypertension, palpitations.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe anorexia, weight loss, dry mouth.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "ADHD", + "val": "Start **PO** 5 mg **BD** (Morning and Midday). Titrate up weekly. Max 40 mg/day. Do not give after 3 PM to avoid insomnia.", + "tags": [] + }, + { + "key": "Narcolepsy", + "val": "**PO** 5-60 mg/day in divided doses.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Dexamphetamine (Generic)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg). Usually scored to halve.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8). Authority Required (PBS). Requires strict specialist permits.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "ADHD, Narcolepsy.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Often used when Methylphenidate fails or causes intolerable side effects. Highly effective but being replaced by Lisdexamfetamine (Vyvanse) to curb abuse.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of substance abuse, symptomatic cardiovascular disease, moderate-to-severe hypertension, hyperthyroidism, concurrent MAOIs, active psychosis.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3 (Risk of premature delivery and neonatal withdrawal).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Dexamfetamine pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs (Fatal hypertensive crisis). Must wait 14 days after stopping MAOI.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Vitamin C / Acidic juices. Acidic urine massively accelerates the excretion of amphetamine, dropping blood levels. Ural / alkaline urine traps the drug in the blood, causing toxicity.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Baseline and routine **BP**, **HR**, **Weight**. Assess for signs of diversion (patient selling pills) or abuse (running out of script early).", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Vitamin C Flush", + "val": "If a patient accidentally overdoses on Dexamfetamine, giving them massive doses of Vitamin C (ascorbic acid) will acidify their urine, trapping the amphetamine in the urine and flushing it out of the body rapidly.", + "tags": [] + }, + { + "key": "The Vyvanse Shift", + "val": "Because Dexamfetamine 5mg tablets are easily crushed and snorted/injected by addicts, guidelines heavily favor switching patients to Vyvanse (Lisdexamfetamine), which is abuse-deterrent.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Enters the presynaptic neuron and forces the dopamine and noradrenaline vesicles to dump their contents directly into the synaptic cleft. Also inhibits reuptake. (Much more forceful mechanism than Methylphenidate).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10 hours. Cleared renally (clearance is heavily dependent on urine pH).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ASPEN DEXAMFETAMINE ARTG/PI and PBS search checked 2026-05-10 for ADHD/stimulant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "CNS Stimulant — Highly potent, pure dextro-isomer of amphetamine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg). Usually scored to halve. (Dexamphetamine (Generic))" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 5 mg **BD** (Morning and Midday). Titrate up weekly. Max 40 mg/day. Do not give after 3 PM to avoid insomnia." + }, + { + "label": "Key Indication Doses", + "value": "ADHD: Start **PO** 5 mg **BD** (Morning and Midday). Titrate up weekly. Max 40 mg/day. Do not give after 3 PM to avoid insomnia. Narcolepsy: **PO** 5-60 mg/day in divided doses." + }, + { + "label": "Best Uses", + "value": "Dexamfetamine is a potent stimulant for ADHD and narcolepsy, but is a Schedule 8 drug with high abuse potential requiring cardiovascular monitoring and strict prescribing controls." + }, + { + "label": "Avoid / Cautions", + "value": "History of substance abuse, symptomatic cardiovascular disease, moderate-to-severe hypertension, hyperthyroidism, concurrent MAOIs, active psychosis. **Pregnancy** Category B3 (Risk of premature delivery and neonatal withdrawal)." + }, + { + "label": "Key Risks", + "value": "Neurological: Extreme abuse, addiction, and diversion risk. HIGH — Insomnia, anxiety, amphetamine psychosis (hallucinations/paranoia), tics. Cardiovascular: Tachycardia, hypertension, palpitations. Gastrointestinal: Severe anorexia, weight loss, dry mouth." + }, + { + "label": "Key Interactions", + "value": "MAOIs (Fatal hypertensive crisis). Must wait 14 days after stopping MAOI. Vitamin C / Acidic juices. Acidic urine massively accelerates the excretion of amphetamine, dropping blood levels. Ural / alkaline urine traps the drug in the blood, causing toxicity." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **BP**, **HR**, **Weight**. Assess for signs of diversion (patient selling pills) or abuse (running out of script early). No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "If a patient accidentally overdoses on Dexamfetamine, giving them massive doses of Vitamin C (ascorbic acid) will acidify their urine, trapping the amphetamine in the urine and flushing it out of the body rapidly." + } + ] + }, + { + "slug": "guanfacine-mr", + "name": "Guanfacine MR", + "class": "ADHD", + "subclass": "Alpha-2 Agonist", + "category": "Psychiatry - ADHD & Stimulants", + "accent": "#d97706", + "tag": "NON-STIMULANT", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "7 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "18 h", + "cls": "", + "flag": "" + }, + { + "label": "Hypotension", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Central Alpha-2A adrenoceptor agonist. Originally a blood pressure medication, now formulated as a modified-release tablet for ADHD. Highly effective for rejection-sensitive, hyperactive, and aggressive ADHD phenotypes.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **7 mg/day** (strictly weight-based for children).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must never be stopped abruptly due to severe rebound hypertension. Causes profound sedation and hypotension during initiation.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Guanfacine MR is a non-stimulant alpha-2 agonist for ADHD as monotherapy or adjunct to stimulants, but causes significant sedation and hypotension especially during titration and must not be stopped abruptly.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Hypotension, bradycardia, syncope. Rebound hypertension if ceased abruptly.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Somnolence, sedation, fatigue (Extremely common, affects > 40% of patients initially).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "LOW — Weight gain (Unlike stimulants which cause weight loss).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "ADHD (Children/Adolescents)", + "val": "Start **PO** 1 mg **OD** (morning or evening). Titrate by 1 mg/week based on clinical response and weight. Max 7 mg/day.", + "tags": [] + }, + { + "key": "Discontinuation", + "val": "MANDATORY — Taper the dose down by 1 mg every 3-7 days to prevent hypertensive crisis.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Intuniv", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Modified Release Tablets (1, 2, 3, 4 mg). MUST be swallowed whole. Do not crush, chew, or break.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "ADHD in children and adolescents (6-17 years), either as monotherapy or adjunct to stimulants.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Severe tic disorders, Tourette's syndrome, PTSD hyperarousal.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The drug of choice for ADHD patients who are highly aggressive, easily triggered/enraged, or have severe tics (which stimulants make worse).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known hypersensitivity. Do not use in patients with significant heart block or baseline bradycardia/hypotension.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Guanfacine MR pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP3A4** inhibitors (Clarithromycin, Ketoconazole) drastically spike Guanfacine levels, causing severe hypotension/bradycardia. Dose must be halved. Inducers (Carbamazepine) require dose doubling.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Antihypertensives (Additive BP drop). CNS Depressants (Additive sedation).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Measure **BP** and **HR** at baseline, during dose escalations, and periodically. Assess for orthostatic drops.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Stimulant Partner", + "val": "Guanfacine is brilliant when combined with Vyvanse/Ritalin. The stimulant fixes the inattention, while the Guanfacine cancels out the stimulant's side effects (it fixes the insomnia, lowers the blood pressure, and stops the tics).", + "tags": [] + }, + { + "key": "The High Fat Trap", + "val": "Do NOT take Guanfacine with a high-fat meal (like a hamburger/bacon). The fat melts the modified-release matrix, causing the entire dose to dump into the blood instantly, leading to acute cardiovascular collapse.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Direct agonist at postsynaptic Alpha-2A receptors in the prefrontal cortex. This strengthens the prefrontal cortex networks, improving working memory, attention, and impulse control, while damping down the amygdala (rage center).", + "tags": [] + }, + { + "key": "Onset", + "val": "2-4 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "18 hours. Metabolised by CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - INTUNIV ARTG/PI and PBS search checked 2026-05-10 for ADHD/stimulant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha-2 Agonist — Central Alpha-2A adrenoceptor agonist." + }, + { + "label": "Route / Formulation", + "value": "Modified Release Tablets (1, 2, 3, 4 mg). MUST be swallowed whole. Do not crush, chew, or break. (Intuniv)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 1 mg **OD** (morning or evening). Titrate by 1 mg/week based on clinical response and weight. Max 7 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "ADHD (Children/Adolescents): Start **PO** 1 mg **OD** (morning or evening). Titrate by 1 mg/week based on clinical response and weight. Max 7 mg/day. Discontinuation: Taper the dose down by 1 mg every 3-7 days to prevent hypertensive crisis." + }, + { + "label": "Best Uses", + "value": "Guanfacine MR is a non-stimulant alpha-2 agonist for ADHD as monotherapy or adjunct to stimulants, but causes significant sedation and hypotension especially during titration and must not be stopped abruptly." + }, + { + "label": "Avoid / Cautions", + "value": "Known hypersensitivity. Do not use in patients with significant heart block or baseline bradycardia/hypotension. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Hypotension, bradycardia, syncope. Rebound hypertension if ceased abruptly. Neurological: Somnolence, sedation, fatigue (Extremely common, affects > 40% of patients initially). Metabolic: Weight gain (Unlike stimulants which cause weight loss)." + }, + { + "label": "Key Interactions", + "value": "**CYP3A4** inhibitors (Clarithromycin, Ketoconazole) drastically spike Guanfacine levels, causing severe hypotension/bradycardia. Dose must be halved. Inducers (Carbamazepine) require dose doubling. Antihypertensives (Additive BP drop). CNS Depressants (Additive sedation)." + }, + { + "label": "Monitoring", + "value": "Measure **BP** and **HR** at baseline, during dose escalations, and periodically. Assess for orthostatic drops. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Guanfacine is brilliant when combined with Vyvanse/Ritalin. The stimulant fixes the inattention, while the Guanfacine cancels out the stimulant's side effects (it fixes the insomnia, lowers the blood pressure, and stops the tics)." + } + ] + }, + { + "slug": "lisdexamfetamine", + "name": "Lisdexamfetamine", + "class": "ADHD", + "subclass": "Prodrug Stimulant", + "category": "Psychiatry - ADHD & Stimulants", + "accent": "#d97706", + "tag": "S8 STIMULANT", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "70 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Duration", + "value": "10–12 h", + "cls": "good", + "flag": "" + }, + { + "label": "Misuse Risk", + "value": "MODERATE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Appetite Loss", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "An ingenious prodrug of dexamfetamine. Inactive in the bottle, it only becomes an active stimulant once enzymes in the red blood cells cleave off an amino acid. Highly abuse-deterrent.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **70 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Provides a smooth, ultra-long 12-14 hour clinical effect. Cannot be snorted or injected for a 'high'.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Lisdexamfetamine is a prodrug stimulant for ADHD with smoother onset and lower abuse potential than dexamfetamine, but still carries cardiovascular risk and Schedule 8 restrictions.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Severe insomnia (if taken late in the day), anxiety, tics, headache. (Abuse potential is significantly lower than IR Dex).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Tachycardia, hypertension.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Profound anorexia, weight loss, dry mouth.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "ADHD", + "val": "Start **PO** 30 mg **OD** in the morning. Titrate up by 20 mg weekly. Target 30-70 mg/day. Max 70 mg/day.", + "tags": [] + }, + { + "key": "Binge Eating Disorder", + "val": "**PO** 30-70 mg **OD** (Off-label/Specialist).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Max 50 mg/day if **eGFR** 15-30. Max 30 mg/day if **eGFR** < 15.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Vyvanse", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (20, 30, 40, 50, 60, 70 mg). Can be opened and dissolved in water (unlike Concerta).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8). Authority Required (PBS) via specialist.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "ADHD (Children > 6 years and Adults).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Binge Eating Disorder (Approved in US, off-label in Aus).", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The gold-standard long-acting amphetamine. Vastly superior to immediate-release Dexamphetamine for maintaining steady focus and preventing drug diversion.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe cardiovascular disease, advanced arteriosclerosis, hyperthyroidism, concurrent MAOIs.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Lisdexamfetamine pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs (Hypertensive crisis).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Urinary alkalizers (Ural) reduce clearance; Ascorbic acid (Vit C) accelerates clearance.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **BP**, **HR**, and **Weight** at every clinical review.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** before escalating to 70mg.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Abuse Deterrent", + "val": "If a drug user crushes Vyvanse and snorts it, or dissolves it and injects it into a vein, absolutely nothing happens. It REQUIRES the enzymes inside red blood cells to activate. This makes it heavily favored by prescribers.", + "tags": [] + }, + { + "key": "The Water Trick", + "val": "If a child cannot swallow capsules, you can open the Vyvanse capsule and dissolve the powder entirely in a glass of water or yogurt. Because it's a prodrug (not a mechanical slow-release matrix), opening the capsule does not destroy its 12-hour slow-release property.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Lisdexamfetamine is purely inactive. Once swallowed, red blood cells slowly cleave off the L-lysine molecule, releasing pure dexamphetamine into the blood at a steady, unchangeable rate.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours (Slower than IR dexamphetamine due to required RBC cleavage).", + "tags": [] + }, + { + "key": "Duration", + "val": "10-14 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Prodrug < 1 hr. Active dexamphetamine 10-12 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - VYVANSE ARTG/PI, TGA safety update, and PBS search checked 2026-05-10 for ADHD/stimulant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Prodrug Stimulant — An ingenious prodrug of dexamfetamine." + }, + { + "label": "Route / Formulation", + "value": "Capsules (20, 30, 40, 50, 60, 70 mg). Can be opened and dissolved in water (unlike Concerta). (Vyvanse)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 30 mg **OD** in the morning. Titrate up by 20 mg weekly. Target 30-70 mg/day. Max 70 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "ADHD: Start **PO** 30 mg **OD** in the morning. Titrate up by 20 mg weekly. Target 30-70 mg/day. Max 70 mg/day. Binge Eating Disorder: **PO** 30-70 mg **OD** (Off-label/Specialist). Renal Impairment: Max 50 mg/day if **eGFR** 15-30. Max 30 mg/day if **eGFR** < 15." + }, + { + "label": "Best Uses", + "value": "Lisdexamfetamine is a prodrug stimulant for ADHD with smoother onset and lower abuse potential than dexamfetamine, but still carries cardiovascular risk and Schedule 8 restrictions." + }, + { + "label": "Avoid / Cautions", + "value": "Severe cardiovascular disease, advanced arteriosclerosis, hyperthyroidism, concurrent MAOIs. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Neurological: Severe insomnia (if taken late in the day), anxiety, tics, headache. (Abuse potential is significantly lower than IR Dex). Cardiovascular: Tachycardia, hypertension. Gastrointestinal: Profound anorexia, weight loss, dry mouth." + }, + { + "label": "Key Interactions", + "value": "MAOIs (Hypertensive crisis). Urinary alkalizers (Ural) reduce clearance; Ascorbic acid (Vit C) accelerates clearance." + }, + { + "label": "Monitoring", + "value": "Monitor **BP**, **HR**, and **Weight** at every clinical review. Check **eGFR** before escalating to 70mg." + }, + { + "label": "Clinical Pearl", + "value": "If a drug user crushes Vyvanse and snorts it, or dissolves it and injects it into a vein, absolutely nothing happens. It REQUIRES the enzymes inside red blood cells to activate. This makes it heavily favored by prescribers." + } + ] + }, + { + "slug": "methylphenidate", + "name": "Methylphenidate", + "class": "ADHD", + "subclass": "CNS Stimulant", + "category": "Psychiatry - ADHD & Stimulants", + "accent": "#d97706", + "tag": "S8 STIMULANT", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "80 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2–3 h (IR)", + "cls": "", + "flag": "" + }, + { + "label": "BP/HR", + "value": "MONITOR", + "cls": "warn", + "flag": "" + }, + { + "label": "Misuse Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Central Nervous System stimulant. Blocks dopamine and noradrenaline reuptake. The first-line therapy for ADHD. Highly effective but strictly controlled due to abuse potential.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **80 mg/day** (Varies slightly based on specific long-acting formulations and specialist state guidelines).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Elevates blood pressure and heart rate. Must monitor cardiovascular status, especially in adults.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Methylphenidate is a first-line stimulant for ADHD with rapid onset and multiple formulations, but is a Schedule 8 controlled substance with cardiovascular monitoring requirements and abuse potential.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Tachycardia, hypertension, palpitations. Rare risk of sudden cardiac death in patients with structural heart defects.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Severe insomnia, anxiety, agitation, tics, psychosis/mania (if bipolar), high addiction/abuse potential.", + "tags": [] + }, + { + "key": "Metabolic/GI", + "val": "HIGH — Severe appetite suppression, weight loss, stunted growth in children.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Children prescribed methylphenidate require growth, weight, appetite, BP, and pulse monitoring." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "ADHD (Immediate Release)", + "val": "**PO** 5-10 mg **BD** to **TDS**. Titrate up weekly. Doses given morning and midday to prevent severe insomnia.", + "tags": [] + }, + { + "key": "ADHD (Extended Release)", + "val": "**PO** 18-54 mg **OD** (Concerta) OR 10-40 mg **OD** (Ritalin LA). Taken strictly in the morning.", + "tags": [] + }, + { + "key": "Narcolepsy", + "val": "**PO** 10-60 mg/day in divided doses.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Ritalin (IR/LA), Concerta (OROS XR), Ritalin 10", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets IR (10 mg). Capsules LA (10, 20, 30, 40 mg). OROS osmotic tablets (18, 27, 36, 54 mg). Do NOT crush XR forms.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8). Authority Required (PBS). Strict state-based prescribing rules (Requires Paediatrician or Psychiatrist authorisation).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Attention Deficit Hyperactivity Disorder (ADHD), Narcolepsy.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Severe refractory depression (specialist only), fatigue in terminal cancer.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The foundational treatment for ADHD. Improves focus, reduces impulsivity, and paradoxically calms hyperactive patients.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Glaucoma, severe hypertension, symptomatic cardiovascular disease, hyperthyroidism, active psychosis, concurrent MAOIs.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Methylphenidate pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs (Fatal hypertensive crisis).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — TCAs, SNRIs (Synergistic cardiovascular toxicity).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Baseline and 6-monthly **BP**, **HR**, **Weight**, and Height (in children).", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Children prescribed methylphenidate require height/weight monitoring as part of routine review." + } + }, + { + "key": "Cardiac", + "val": "Consider baseline **ECG** if there is a family history of sudden cardiac death.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Afternoon Crash", + "val": "Immediate release (Ritalin 10) wears off abruptly after 3-4 hours, causing a severe 'rebound' crash of irritability and hyperactivity. Transitioning to long-acting formulations (Concerta) smooths this out completely.", + "tags": [] + }, + { + "key": "The Ghost Pill", + "val": "Concerta uses an OROS osmotic pump. The drug is pushed out through a laser-drilled hole, and the empty, intact plastic shell passes in the stool. Reassure parents this is normal.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits the reuptake of dopamine (DAT) and noradrenaline (NET) in the presynaptic neuron, leaving more transmitters in the synaptic cleft of the prefrontal cortex and striatum.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 20-30 mins (IR).", + "tags": [] + }, + { + "key": "Duration", + "val": "3-4 h (IR), 8-12 h (Concerta/LA).", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours. Cleared by de-esterification (not dependent on CYP450).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - RITALIN/CONCERTA ARTG/PI and PBS search checked 2026-05-10 for ADHD/stimulant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "CNS Stimulant — Central Nervous System stimulant." + }, + { + "label": "Route / Formulation", + "value": "Tablets IR (10 mg). Capsules LA (10, 20, 30, 40 mg). OROS osmotic tablets (18, 27, 36, 54 mg). Do NOT crush XR forms. (Ritalin (IR/LA), Concerta (OROS XR), Ritalin 10)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5-10 mg **BD** to **TDS**. Titrate up weekly. Doses given morning and midday to prevent severe insomnia. Max **80 mg/day** (Varies slightly based on specific long-acting formulations and specialist state guidelines)." + }, + { + "label": "Key Indication Doses", + "value": "ADHD (Immediate Release): **PO** 5-10 mg **BD** to **TDS**. Titrate up weekly. Doses given morning and midday to prevent severe insomnia. ADHD (Extended Release): **PO** 18-54 mg **OD** (Concerta) OR 10-40 mg **OD** (Ritalin LA). Taken strictly in the morning. Narcolepsy: **PO** 10-60 mg/day in divided doses." + }, + { + "label": "Best Uses", + "value": "Methylphenidate is a first-line stimulant for ADHD with rapid onset and multiple formulations, but is a Schedule 8 controlled substance with cardiovascular monitoring requirements and abuse potential." + }, + { + "label": "Avoid / Cautions", + "value": "Glaucoma, severe hypertension, symptomatic cardiovascular disease, hyperthyroidism, active psychosis, concurrent MAOIs. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Tachycardia, hypertension, palpitations. Rare risk of sudden cardiac death in patients with structural heart defects. Neurological: Severe insomnia, anxiety, agitation, tics, psychosis/mania (if bipolar), high addiction/abuse potential. Metabolic/GI: Severe appetite suppression, weight loss, stunted growth in children." + }, + { + "label": "Key Interactions", + "value": "MAOIs (Fatal hypertensive crisis). TCAs, SNRIs (Synergistic cardiovascular toxicity)." + }, + { + "label": "Monitoring", + "value": "Baseline and 6-monthly **BP**, **HR**, **Weight**, and Height (in children). Consider baseline **ECG** if there is a family history of sudden cardiac death." + }, + { + "label": "Clinical Pearl", + "value": "Immediate release (Ritalin 10) wears off abruptly after 3-4 hours, causing a severe 'rebound' crash of irritability and hyperactivity. Transitioning to long-acting formulations (Concerta) smooths this out completely." + } + ] + }, + { + "slug": "alimemazine", + "name": "Alimemazine", + "class": "Sedative", + "subclass": "Phenothiazine Antihistamine", + "category": "Psychiatry - Acute Calming & Sedation", + "accent": "#e11d48", + "tag": "ANTIHISTAMINE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "100 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5 h", + "cls": "", + "flag": "" + }, + { + "label": "Sedation", + "value": "PROFOUND", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Anticholinergic", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "First-generation phenothiazine antihistamine (also known as Trimeprazine). Highly sedating, historically used as a pediatric sedative and strong anti-pruritic. Largely obsolete in modern medicine.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **100 mg/day** (Adults). Max doses in children strictly weight-based.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Severe risk of fatal respiratory depression in children under 2 years old.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Alimemazine is a sedating phenothiazine antihistamine for pruritus and pre-medication, but causes significant sedation and has anticholinergic effects unsuitable for elderly patients.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Profound sedation, hangover, paradoxical excitation in children. EPS and acute dystonia (due to phenothiazine structure).", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Respiratory", + "val": "CRITICAL — Fatal respiratory depression in infants/toddlers.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe dry mouth, constipation.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Pruritus / Urticaria (Adults)", + "val": "**PO** 10 mg **BD** or **TDS**. Max 100 mg/day in severe cases.", + "tags": [] + }, + { + "key": "Pre-operative Sedation (Children > 2 yrs)", + "val": "**PO** 2-4 mg/kg given 1-2 hours before surgery (Rarely used today).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Vallergan, Vallergan Forte", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg). Oral syrup (7.5 mg/5mL, Forte is 30 mg/5mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Prescription Only (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Urticaria, severe pruritus, pediatric pre-medication sedation.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Largely replaced by Promethazine for severe sedation/itch, or safer 2nd-gen agents (Cetirizine) for standard allergies.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Children < 2 years old. Severe hepatic or renal impairment. Narrow-angle glaucoma.", + "tags": [], + "patient": { + "factors": ["renal", "hepatic", "paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 60 + }, + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Elderly", + "val": "CRITICAL — High risk of anticholinergic delirium and falls.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive CNS depression with Opioids, Benzos, and Alcohol.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive anticholinergic burden with TCAs and Antipsychotics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **SpO2** and **RR** closely if given to children for sedation.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Phenothiazine Lineage", + "val": "Alimemazine is structurally a phenothiazine (like Chlorpromazine or Prochlorperazine). While marketed as an 'allergy' medication, it can cause the exact same terrifying locked-jaw dystonic reactions as standard antipsychotics.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive antagonist at H1 histamine receptors. Significant blockade of muscarinic, dopaminergic, and alpha-1 receptors, causing intense sedation and dry mouth.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h (Sedation can last much longer).", + "tags": [] + }, + { + "key": "Half-life", + "val": "5 hours. Extensively hepatically metabolised.", + "tags": [] + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Phenothiazine Antihistamine — First-generation phenothiazine antihistamine (also known as Trimeprazine)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg). Oral syrup (7.5 mg/5mL, Forte is 30 mg/5mL). (Vallergan, Vallergan Forte)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10 mg **BD** or **TDS**. Max 100 mg/day in severe cases." + }, + { + "label": "Key Indication Doses", + "value": "Severe Pruritus / Urticaria (Adults): **PO** 10 mg **BD** or **TDS**. Max 100 mg/day in severe cases. Pre-operative Sedation (Children > 2 yrs): **PO** 2-4 mg/kg given 1-2 hours before surgery (Rarely used today)." + }, + { + "label": "Best Uses", + "value": "Alimemazine is a sedating phenothiazine antihistamine for pruritus and pre-medication, but causes significant sedation and has anticholinergic effects unsuitable for elderly patients." + }, + { + "label": "Avoid / Cautions", + "value": "Children < 2 years old. Severe hepatic or renal impairment. Narrow-angle glaucoma." + }, + { + "label": "Key Risks", + "value": "Neurological: Profound sedation, hangover, paradoxical excitation in children. EPS and acute dystonia (due to phenothiazine structure). Respiratory: Fatal respiratory depression in infants/toddlers. Gastrointestinal: Severe dry mouth, constipation." + }, + { + "label": "Key Interactions", + "value": "Additive CNS depression with Opioids, Benzos, and Alcohol. Additive anticholinergic burden with TCAs and Antipsychotics." + }, + { + "label": "Monitoring", + "value": "Monitor **SpO2** and **RR** closely if given to children for sedation." + }, + { + "label": "Clinical Pearl", + "value": "Alimemazine is structurally a phenothiazine (like Chlorpromazine or Prochlorperazine). While marketed as an 'allergy' medication, it can cause the exact same terrifying locked-jaw dystonic reactions as standard antipsychotics." + } + ] + }, + { + "slug": "benzatropine", + "name": "Benzatropine", + "class": "Adjunct", + "subclass": "Anticholinergic", + "category": "Psychiatry - Acute Calming & Sedation", + "accent": "#e11d48", + "tag": "ANTICHOLINERGIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "6 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12-24 h", + "cls": "", + "flag": "" + }, + { + "label": "Dystonia", + "value": "RESCUE DRUG", + "cls": "good", + "flag": "warn" + }, + { + "label": "Delirium", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent central anticholinergic. The definitive antidote for acute dystonic reactions and severe Parkinsonism caused by First-Generation Antipsychotics.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **6 mg/day** (Doses > 4mg/day strongly risk toxic psychosis).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly toxic to the elderly. Causes frank anticholinergic delirium, profound urinary retention, and severe constipation.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Benzatropine is an anticholinergic for acute drug-induced dystonia and parkinsonism, but causes significant anticholinergic toxicity and should not be used for tardive dyskinesia.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Toxic psychosis, hallucinations, delirium, memory loss (especially in older adults).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Older adults require monitoring for anticholinergic delirium, cognitive impairment, urinary retention, and falls." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe dry mouth, paralytic ileus, constipation.", + "tags": [] + }, + { + "key": "Ocular", + "val": "HIGH — Blurred vision, precipitation of narrow-angle glaucoma.", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "HIGH — Urinary retention.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Dystonic Reaction (Oculogyric Crisis/Torticollis)", + "val": "**IM** or **IV** 1-2 mg STAT. Repeat after 15 mins if no response. Follow with oral therapy for 3-5 days to prevent relapse.", + "tags": [] + }, + { + "key": "Antipsychotic-Induced Parkinsonism", + "val": "**PO** 1-2 mg **OD** to **BD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Cogentin, Benztrop", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (2 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (2 mg/2 mL) for **IM** or **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Drug-induced extrapyramidal symptoms (EPS) excluding tardive dyskinesia. Adjunct in Parkinson's disease.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Emergency rescue drug stored on every psychiatric and ED ward for antipsychotic reactions.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Untreated narrow-angle glaucoma, mechanical bowel obstruction, severe BPH, tardive dyskinesia (worsens it).", + "tags": [] + }, + { + "key": "Elderly & Dementia", + "val": "CRITICAL — Strictly avoid. Will cause immediate, severe delirium and falls.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive anticholinergic toxidrome with TCAs (Amitriptyline), antihistamines (Promethazine), and Clozapine (risk of toxic megacolon).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor bowel and bladder output. A young male on Haloperidol + Benzatropine is at extreme risk of sudden urinary retention requiring a catheter.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Magic Fix", + "val": "A dystonic reaction (neck spasming backward, jaw locked, eyes rolled up) is terrifying for the patient. Pushing 1-2mg of IV Benzatropine is one of the most rewarding moments in medicine; the spasm literally melts away within 60 seconds.", + "tags": [] + }, + { + "key": "The TD Trap", + "val": "Benzatropine cures acute EPS, but it actually WORSENS Tardive Dyskinesia (TD - chronic lip smacking/tongue rolling). Never prescribe Benzatropine for TD.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive antagonist of muscarinic acetylcholine receptors in the striatum. By blocking acetylcholine, it restores the balance between dopamine (which is blocked by antipsychotics) and acetylcholine, resolving the severe muscle spasms.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 1-5 mins. **IM** 15 mins. **PO** 1 hour.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12-24 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - BENZTROP ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Anticholinergic — Potent central anticholinergic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (2 mg). (Cogentin, Benztrop)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** or **IV** 1-2 mg STAT. Repeat after 15 mins if no response. Follow with oral therapy for 3-5 days to prevent relapse. Max **6 mg/day** (Doses > 4mg/day strongly risk toxic psychosis)." + }, + { + "label": "Key Indication Doses", + "value": "Acute Dystonic Reaction (Oculogyric Crisis/Torticollis): **IM** or **IV** 1-2 mg STAT. Repeat after 15 mins if no response. Follow with oral therapy for 3-5 days to prevent relapse. Antipsychotic-Induced Parkinsonism: **PO** 1-2 mg **OD** to **BD**." + }, + { + "label": "Best Uses", + "value": "Benzatropine is an anticholinergic for acute drug-induced dystonia and parkinsonism, but causes significant anticholinergic toxicity and should not be used for tardive dyskinesia." + }, + { + "label": "Avoid / Cautions", + "value": "Untreated narrow-angle glaucoma, mechanical bowel obstruction, severe BPH, tardive dyskinesia (worsens it)." + }, + { + "label": "Key Risks", + "value": "Neurological: Toxic psychosis, hallucinations, delirium, memory loss (especially in older adults). Gastrointestinal: Severe dry mouth, paralytic ileus, constipation. Ocular: Blurred vision, precipitation of narrow-angle glaucoma. Genitourinary: Urinary retention." + }, + { + "label": "Key Interactions", + "value": "Additive anticholinergic toxidrome with TCAs (Amitriptyline), antihistamines (Promethazine), and Clozapine (risk of toxic megacolon)." + }, + { + "label": "Monitoring", + "value": "Monitor bowel and bladder output. A young male on Haloperidol + Benzatropine is at extreme risk of sudden urinary retention requiring a catheter." + }, + { + "label": "Clinical Pearl", + "value": "A dystonic reaction (neck spasming backward, jaw locked, eyes rolled up) is terrifying for the patient. Pushing 1-2mg of IV Benzatropine is one of the most rewarding moments in medicine; the spasm literally melts away within 60 seconds." + } + ] + }, + { + "slug": "cyproheptadine", + "name": "Cyproheptadine", + "class": "Antidote", + "subclass": "5HT2A Antagonist", + "category": "Psychiatry - Acute Calming & Sedation", + "accent": "#e11d48", + "tag": "ANTIDOTE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "32 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "16 h", + "cls": "", + "flag": "" + }, + { + "label": "Serotonin Synd.", + "value": "RESCUE DRUG", + "cls": "good", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "PROFOUND", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "First-generation antihistamine with exceptionally potent anti-serotonergic (5-HT2A) properties. The definitive oral antidote for life-threatening Serotonin Syndrome.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **32 mg/day** (Adults).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Only available orally. If a patient is seizing or comatose from Serotonin Syndrome, the tablets must be crushed and given via NGT.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Cyproheptadine is a first-generation antihistamine used as an appetite stimulant and serotonin syndrome antidote, but causes significant sedation and weight gain.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Profound sedation, dizziness, confusion, paradoxical excitation in children.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Children require monitoring for paradoxical excitation and sedation." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Intense appetite stimulation, weight gain, dry mouth (anticholinergic effect).", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "MODERATE — Urinary retention.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Serotonin Syndrome (Antidote)", + "val": "**PO** / **NGT** 12 mg STAT, followed by 2 mg every 2 hours until symptoms resolve (or 8 mg q6h). Max 32 mg/day.", + "tags": [] + }, + { + "key": "Severe Pruritus / Urticaria", + "val": "**PO** 4-8 mg **TDS**.", + "tags": [] + }, + { + "key": "Appetite Stimulation (Off-Label)", + "val": "**PO** 2-4 mg **TDS**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Periactin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (4 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S3) or Prescription (S4) depending on indication.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Allergic dermatoses, severe pruritus.", + "tags": ["TGA"] + }, + { + "key": "Off-Label", + "val": "Serotonin Syndrome antidote, appetite stimulation in anorexia, SSRI-induced sexual dysfunction.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Emergency toxicology rescue drug for SSRI/Tramadol/MAOI overdoses presenting with clonus and hyperthermia.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Narrow-angle glaucoma, severe BPH/urinary retention, concurrent MAOI use (paradoxical, but standard for most antihistamines), neonates.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Cyproheptadine pregnancy row is informational; it should not trigger an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive CNS depression with Benzodiazepines, Alcohol, and Opioids.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive anticholinergic burden with TCAs and Antipsychotics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — In Serotonin Syndrome, monitor core temperature, rigidity, and clonus strictly. Ensure NGT placement is correct before pushing crushed tablets.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The NGT Requirement", + "val": "Because Serotonin Syndrome causes rigidity, altered consciousness, and hyperthermia, patients often cannot swallow pills safely. Crushing Cyproheptadine and flushing it down a nasogastric tube is a mandatory ICU skill.", + "tags": [] + }, + { + "key": "The Hunger Pill", + "val": "Because of its intense anti-serotonin action in the hypothalamus, it completely turns off the brain's satiety (fullness) signal. It is heavily utilized off-label to force weight gain in severe anorexia nervosa or cancer cachexia.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent antagonist at H1 (histamine) and 5-HT2A (serotonin) receptors. Also exerts strong anticholinergic (muscarinic) and mild calcium-channel blocking effects.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "16 hours. Hepatically metabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - PERIACTIN ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "5HT2A Antagonist — First-generation antihistamine with exceptionally potent anti-serotonergic (5-HT2A) properties." + }, + { + "label": "Route / Formulation", + "value": "Tablets (4 mg). (Periactin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** / **NGT** 12 mg STAT, followed by 2 mg every 2 hours until symptoms resolve (or 8 mg q6h). Max 32 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Serotonin Syndrome (Antidote): **PO** / **NGT** 12 mg STAT, followed by 2 mg every 2 hours until symptoms resolve (or 8 mg q6h). Max 32 mg/day. Severe Pruritus / Urticaria: **PO** 4-8 mg **TDS**. Appetite Stimulation (Off-Label): **PO** 2-4 mg **TDS**." + }, + { + "label": "Best Uses", + "value": "Cyproheptadine is a first-generation antihistamine used as an appetite stimulant and serotonin syndrome antidote, but causes significant sedation and weight gain." + }, + { + "label": "Avoid / Cautions", + "value": "Narrow-angle glaucoma, severe BPH/urinary retention, concurrent MAOI use (paradoxical, but standard for most antihistamines), neonates. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Neurological: Profound sedation, dizziness, confusion, paradoxical excitation in children. Gastrointestinal: Intense appetite stimulation, weight gain, dry mouth (anticholinergic effect). Genitourinary: Urinary retention." + }, + { + "label": "Key Interactions", + "value": "Additive CNS depression with Benzodiazepines, Alcohol, and Opioids. Additive anticholinergic burden with TCAs and Antipsychotics." + }, + { + "label": "Monitoring", + "value": "In Serotonin Syndrome, monitor core temperature, rigidity, and clonus strictly. Ensure NGT placement is correct before pushing crushed tablets." + }, + { + "label": "Clinical Pearl", + "value": "Because Serotonin Syndrome causes rigidity, altered consciousness, and hyperthermia, patients often cannot swallow pills safely. Crushing Cyproheptadine and flushing it down a nasogastric tube is a mandatory ICU skill." + } + ] + }, + { + "slug": "dexmedetomidine", + "name": "Dexmedetomidine", + "class": "Sedative", + "subclass": "Central Alpha-2 Agonist", + "category": "Psychiatry - Acute Calming & Sedation", + "accent": "#e11d48", + "tag": "ICU IV ONLY", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1.4 mcg/kg/hr", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "Airway", + "value": "PRESERVED", + "cls": "good", + "flag": "" + }, + { + "label": "Bradycardia", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly selective central alpha-2 agonist. Provides unique 'rousable sedation' (cooperative sedation) and analgesia without depressing respiratory drive.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1.4 mcg/kg/hr** (via continuous IV infusion).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Frequently causes profound bradycardia and hypotension. Strictly for ICU/OT use.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dexmedetomidine is a selective alpha-2 agonist for ICU sedation allowing cooperative sedation without respiratory depression, but causes significant bradycardia and hypotension.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Severe bradycardia (can lead to sinus arrest), hypotension. (A transient hypertensive spike can occur if a rapid loading dose is given).", + "tags": [] + }, + { + "key": "Respiratory", + "val": "SAFE — Zero clinically significant respiratory depression.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Dry mouth, nausea.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "ICU Sedation", + "val": "**IV Infusion** Start at 0.2 - 0.7 mcg/kg/hr. Titrate to desired RASS (Richmond Agitation-Sedation Scale) score. Loading doses (1 mcg/kg over 10 mins) are increasingly avoided due to severe bradycardia risk.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "MANDATORY — Reduce dose in severe liver disease (prolonged clearance).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Precedex", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (200 mcg/2 mL) for **IV** infusion. Must be diluted.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital ICU/OT supply only. S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Sedation of initially intubated and mechanically ventilated patients in ICU. Procedural sedation.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Allows for early extubation in ICU because the patient can be awake and cooperative while still comfortable, unlike Propofol which induces a coma.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe baseline bradycardia, advanced heart block without a pacemaker, unresuscitated hypovolemia.", + "tags": [] + }, + { + "key": "Elderly", + "val": "CAUTION — High risk of profound bradycardia. Titrate very slowly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "monitor", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Older adults require slow titration and close heart-rate/BP monitoring." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Beta-blockers, Digoxin, Amiodarone (Massive additive bradycardia risk).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Enhances the effect of opioids and propofol, requiring their doses to be slashed.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Continuous **ECG** and **BP** monitoring. Stop infusion if HR drops dangerously low.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Rousable Sedation", + "val": "A patient on a Dexmedetomidine infusion might look deeply asleep, but if you say their name, they will open their eyes, follow commands, and then drift back to sleep. This makes neuro-assessments in ICU incredibly easy compared to Midazolam/Propofol.", + "tags": [] + }, + { + "key": "The Tachycardia Fix", + "val": "It is excellent for sedating patients withdrawing from alcohol or amphetamines, as it treats the agitation while directly suppressing their hyperadrenergic tachycardia/hypertension.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Agonises alpha-2 receptors in the locus coeruleus, inhibiting norepinephrine release. This induces a state mimicking natural NREM sleep.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 5-10 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "1-2 h post-infusion.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2 hours. Hepatically metabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DEXMEDETOMIDINE VIATRIS ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Central Alpha-2 Agonist — Highly selective central alpha-2 agonist." + }, + { + "label": "Route / Formulation", + "value": "Vials (200 mcg/2 mL) for **IV** infusion. Must be diluted. (Precedex)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV Infusion** Start at 0.2 - 0.7 mcg/kg/hr. Titrate to desired RASS (Richmond Agitation-Sedation Scale) score. Loading doses (1 mcg/kg over 10 mins) are increasingly avoided due to severe bradycardia risk. Max **1.4 mcg/kg/hr** (via continuous IV infusion)." + }, + { + "label": "Key Indication Doses", + "value": "ICU Sedation: **IV Infusion** Start at 0.2 - 0.7 mcg/kg/hr. Titrate to desired RASS (Richmond Agitation-Sedation Scale) score. Loading doses (1 mcg/kg over 10 mins) are increasingly avoided due to severe bradycardia risk. Hepatic Impairment: Reduce dose in severe liver disease (prolonged clearance)." + }, + { + "label": "Best Uses", + "value": "Dexmedetomidine is a selective alpha-2 agonist for ICU sedation allowing cooperative sedation without respiratory depression, but causes significant bradycardia and hypotension." + }, + { + "label": "Avoid / Cautions", + "value": "Severe baseline bradycardia, advanced heart block without a pacemaker, unresuscitated hypovolemia." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Severe bradycardia (can lead to sinus arrest), hypotension. (A transient hypertensive spike can occur if a rapid loading dose is given). Respiratory: Zero clinically significant respiratory depression. Gastrointestinal: Dry mouth, nausea." + }, + { + "label": "Key Interactions", + "value": "Beta-blockers, Digoxin, Amiodarone (Massive additive bradycardia risk). Enhances the effect of opioids and propofol, requiring their doses to be slashed." + }, + { + "label": "Monitoring", + "value": "Continuous **ECG** and **BP** monitoring. Stop infusion if HR drops dangerously low." + }, + { + "label": "Clinical Pearl", + "value": "A patient on a Dexmedetomidine infusion might look deeply asleep, but if you say their name, they will open their eyes, follow commands, and then drift back to sleep. This makes neuro-assessments in ICU incredibly easy compared to Midazolam/Propofol." + } + ] + }, + { + "slug": "droperidol", + "name": "Droperidol", + "class": "Sedative", + "subclass": "Butyrophenone", + "category": "Psychiatry - Acute Calming & Sedation", + "accent": "#e11d48", + "tag": "ED SEDATION", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg STAT", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "QTc Risk", + "value": "CRITICAL RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "RAPID", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent, ultra-fast-acting butyrophenone. The gold standard in emergency departments for severe, undifferentiated behavioral disturbance and violence.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg** (STAT IM dose) or **20 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Infamous for dose-dependent QTc prolongation. Black Box warning in the US, though Australian ED guidelines strongly endorse its use in acute agitation.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Droperidol is a potent butyrophenone antiemetic and antipsychotic for acute agitation, but prolongs QTc significantly and requires ECG monitoring before administration.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — **QTc** prolongation and Torsades de Pointes. Hypotension (due to alpha-1 blockade).", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "HIGH — Extrapyramidal side effects (EPS), acute dystonia, severe akathisia (often emerges 24h later).", + "tags": [] + }, + { + "key": "Respiratory", + "val": "SAFE — Does not depress respiratory drive (unlike benzodiazepines).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Acute Agitation (Code Black)", + "val": "**IM** 5-10 mg STAT. May repeat 5 mg after 15 mins if no effect. (Use 10 mg for violently agitated adults).", + "tags": [] + }, + { + "key": "Severe Nausea/Vomiting", + "val": "**IV** 0.625 - 1.25 mg STAT (Off-label, highly effective antiemetic).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Max 2.5 - 5 mg STAT. High risk of excessive sedation and EPS.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Droleptan", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (10 mg/2 mL) for **IM** or **IV** use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital emergency/ED supply. S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute behavioral disturbance, severe nausea/vomiting, procedural sedation adjunct.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "The first-line chemical restraint in WA Health EDs for violent, uncooperative patients. Faster and more reliable than IM Haloperidol.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known prolonged QTc > 500 ms, Parkinson's disease, severe CNS depression.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 500 + } + }, + "note": "Droperidol absolute contraindication row uses QTc >500 ms; lower QTc prolongation remains a caution/monitoring prompt elsewhere." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Droperidol pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Other QTc prolonging agents (Amiodarone, Sotalol, Macrolides).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive sedation with Benzodiazepines/Opioids.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Perform a baseline **ECG** as soon as the patient is calm enough to permit it to check QTc.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "MANDATORY — Monitor **SpO2**, **RR**, and Sedation Score. Droperidol lowers the seizure threshold slightly; observe if given for alcohol withdrawal.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Akathisia Bounce", + "val": "Droperidol fixes the violent agitation in 10 minutes, but 12 hours later the patient may become severely restless, pacing, and unable to sit still. This is Droperidol-induced akathisia, NOT a return of their underlying psychosis. Treat with Diazepam or Benzatropine.", + "tags": [] + }, + { + "key": "The Antiemetic Hack", + "val": "In tiny IV micro-doses (0.625 mg), Droperidol is one of the most effective antiemetics for refractory cannabinoid hyperemesis syndrome or severe migraines in the ED.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent central dopamine (D2) receptor antagonist. Produces intense neurolepsis, tranquility, and antiemetic effects. Mild alpha-1 blockade.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IM** 3-10 mins. **IV** 1-2 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2 hours. Cleared hepatically.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DROPERIDOL LUPIN ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Butyrophenone — Highly potent, ultra-fast-acting butyrophenone." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (10 mg/2 mL) for **IM** or **IV** use. (Droleptan)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 5-10 mg STAT. May repeat 5 mg after 15 mins if no effect. (Use 10 mg for violently agitated adults). Max **10 mg** (STAT IM dose) or **20 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Severe Acute Agitation (Code Black): **IM** 5-10 mg STAT. May repeat 5 mg after 15 mins if no effect. (Use 10 mg for violently agitated adults). Severe Nausea/Vomiting: **IV** 0.625 - 1.25 mg STAT (Off-label, highly effective antiemetic). Elderly / Frail: Max 2.5 - 5 mg STAT. High risk of excessive sedation and EPS." + }, + { + "label": "Best Uses", + "value": "Droperidol is a potent butyrophenone antiemetic and antipsychotic for acute agitation, but prolongs QTc significantly and requires ECG monitoring before administration." + }, + { + "label": "Avoid / Cautions", + "value": "Known prolonged QTc > 500 ms, Parkinson's disease, severe CNS depression. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: **QTc** prolongation and Torsades de Pointes. Hypotension (due to alpha-1 blockade). Neurological: Extrapyramidal side effects (EPS), acute dystonia, severe akathisia (often emerges 24h later). Respiratory: Does not depress respiratory drive (unlike benzodiazepines)." + }, + { + "label": "Key Interactions", + "value": "Other QTc prolonging agents (Amiodarone, Sotalol, Macrolides). Additive sedation with Benzodiazepines/Opioids." + }, + { + "label": "Monitoring", + "value": "Perform a baseline **ECG** as soon as the patient is calm enough to permit it to check QTc. Monitor **SpO2**, **RR**, and Sedation Score. Droperidol lowers the seizure threshold slightly; observe if given for alcohol withdrawal." + }, + { + "label": "Clinical Pearl", + "value": "Droperidol fixes the violent agitation in 10 minutes, but 12 hours later the patient may become severely restless, pacing, and unable to sit still. This is Droperidol-induced akathisia, NOT a return of their underlying psychosis. Treat with Diazepam or Benzatropine." + } + ] + }, + { + "slug": "ketamine", + "name": "Ketamine", + "class": "Novel", + "subclass": "NMDA Antagonist", + "category": "Psychiatry - Acute Calming & Sedation", + "accent": "#e11d48", + "tag": "NMDA", + "schedule": "S8", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-3 h", + "cls": "", + "flag": "" + }, + { + "label": "Airway", + "value": "PRESERVED", + "cls": "good", + "flag": "" + }, + { + "label": "Emergence", + "value": "DELIRIUM RISK", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Dissociative anaesthetic and powerful analgesic. Unique because it preserves respiratory drive and airway reflexes, while simultaneously boosting blood pressure and heart rate.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated strictly to clinical effect (Analgesia vs Sedation vs Anaesthesia).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The ultimate 'safe' sedative for the shocked, hypotensive, or actively asthmatic patient in the ED/ICU.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ketamine is a unique dissociative anaesthetic and analgesic with emerging use in treatment-resistant depression, but causes emergence phenomena (hallucinations) and raises intracranial pressure.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Emergence phenomenon (terrifying hallucinations, vivid dreams, severe agitation as the drug wears off).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Tachycardia, hypertension (Usually a desired effect in trauma, but dangerous in severe ischemic heart disease).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Hypersalivation (drooling/secretions), vomiting.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Severe Analgesia", + "val": "**IV** 0.1 - 0.3 mg/kg bolus. OR **SC** / **IM** 0.5 mg/kg.", + "tags": [] + }, + { + "key": "Procedural Sedation", + "val": "**IV** 0.5 - 1 mg/kg. (Often combined with low-dose midazolam to prevent emergence delirium).", + "tags": [] + }, + { + "key": "Severe Agitation / Excited Delirium", + "val": "**IM** 4 - 5 mg/kg STAT (Produces rapid, deep dissociation in violently agitated patients).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Ketalar", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (200 mg/2 mL) for **IV**, **IM**, or **SC** use. Can also be given intranasally via atomiser.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted (S8). Hospital supply only.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Procedural sedation, refractory severe pain, induction of anaesthesia.", + "tags": ["TGA"] + }, + { + "key": "Off-Label", + "val": "Treatment-resistant depression (sub-anesthetic infusions), extreme acute behavioral disturbance.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The go-to drug for painfully relocating joints in ED, or safely sedating a hypotensive trauma patient.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe uncontrolled hypertension, recent MI, aneurysms, conditions where a sudden spike in BP is fatal.", + "tags": [] + }, + { + "key": "Psychiatric", + "val": "CAUTION — Schizophrenia (Can exacerbate psychosis).", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive sedation with Benzos/Opioids, but Benzos are actually *beneficial* to prevent emergence delirium.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Keep the patient in a quiet, dark environment while recovering to minimize sensory overload and emergence delirium. Have suction ready for hypersalivation.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Continuous **ECG**, **BP**, and **SpO2** monitoring during use.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Asthma Savior", + "val": "Because Ketamine releases massive amounts of catecholamines, it acts as a potent bronchodilator. It is the absolute induction agent of choice for intubating a patient in status asthmaticus.", + "tags": [] + }, + { + "key": "The Airway Myth", + "val": "While it usually preserves airway reflexes, pushing Ketamine too fast IV can still cause brief apnoea or laryngospasm. You must always have full airway equipment ready.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Non-competitive NMDA receptor antagonist. Blocks glutamate, physically disconnecting the thalamocortical and limbic systems (dissociation). Also inhibits catecholamine reuptake (boosting HR/BP).", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 30 seconds. **IM** 3-4 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "15-30 mins (Anaesthesia), up to 2 hours (Analgesia).", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours. Hepatically metabolised to norketamine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - KETAMINE INTERPHARMA ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "NMDA Antagonist — Dissociative anaesthetic and powerful analgesic." + }, + { + "label": "Route / Formulation", + "value": "Vials (200 mg/2 mL) for **IV**, **IM**, or **SC** use. Can also be given intranasally via atomiser. (Ketalar)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 0.1 - 0.3 mg/kg bolus. OR **SC** / **IM** 0.5 mg/kg. Titrated strictly to clinical effect (Analgesia vs Sedation vs Anaesthesia)." + }, + { + "label": "Key Indication Doses", + "value": "Acute Severe Analgesia: **IV** 0.1 - 0.3 mg/kg bolus. OR **SC** / **IM** 0.5 mg/kg. Procedural Sedation: **IV** 0.5 - 1 mg/kg. (Often combined with low-dose midazolam to prevent emergence delirium). Severe Agitation / Excited Delirium: **IM** 4 - 5 mg/kg STAT (Produces rapid, deep dissociation in violently agitated patients)." + }, + { + "label": "Best Uses", + "value": "Ketamine is a unique dissociative anaesthetic and analgesic with emerging use in treatment-resistant depression, but causes emergence phenomena (hallucinations) and raises intracranial pressure." + }, + { + "label": "Avoid / Cautions", + "value": "Severe uncontrolled hypertension, recent MI, aneurysms, conditions where a sudden spike in BP is fatal." + }, + { + "label": "Key Risks", + "value": "Neurological: Emergence phenomenon (terrifying hallucinations, vivid dreams, severe agitation as the drug wears off). Cardiovascular: Tachycardia, hypertension (Usually a desired effect in trauma, but dangerous in severe ischemic heart disease). Gastrointestinal: Hypersalivation (drooling/secretions), vomiting." + }, + { + "label": "Key Interactions", + "value": "Additive sedation with Benzos/Opioids, but Benzos are actually *beneficial* to prevent emergence delirium." + }, + { + "label": "Monitoring", + "value": "Keep the patient in a quiet, dark environment while recovering to minimize sensory overload and emergence delirium. Have suction ready for hypersalivation. Continuous **ECG**, **BP**, and **SpO2** monitoring during use." + }, + { + "label": "Clinical Pearl", + "value": "Because Ketamine releases massive amounts of catecholamines, it acts as a potent bronchodilator. It is the absolute induction agent of choice for intubating a patient in status asthmaticus." + } + ] + }, + { + "slug": "levomepromazine", + "name": "Levomepromazine", + "class": "Antipsychotic", + "subclass": "FGA / Sedative", + "category": "Psychiatry - Acute Calming & Sedation", + "accent": "#e11d48", + "tag": "FGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "30 h", + "cls": "", + "flag": "" + }, + { + "label": "Hypotension", + "value": "SEVERE RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "PROFOUND", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Also known as Methotrimeprazine. Extremely sedating, low-potency phenothiazine. The absolute 'heavy artillery' for palliative care terminal agitation and refractory nausea.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg/day** (Usually 12.5 - 50 mg/day in palliative care).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Causes massive, treatment-limiting orthostatic hypotension. The patient must remain in bed after a dose.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Levomepromazine is a highly sedating phenothiazine used in palliative care for refractory nausea and terminal agitation, but causes profound hypotension and sedation at higher doses.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Profound, fainting-level orthostatic hypotension. Reflex tachycardia, **QTc** prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "HIGH — Extreme sedation, lethargy, lowers seizure threshold. (Less EPS than Haloperidol due to strong anticholinergic properties).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe dry mouth, constipation.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Palliative Agitation / Nausea", + "val": "**PO** or **SC** 6.25 - 12.5 mg q4-8h PRN. Or continuous SC syringe driver (25-100 mg/24h).", + "tags": [] + }, + { + "key": "Severe Acute Psychosis", + "val": "**PO** 50-200 mg/day (Rarely used for this indication today).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Start at micro-doses (e.g., 3.125 mg to 6.25 mg).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nozinan", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (25 mg, 100 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (25 mg/1 mL) for **SC** or **IM** use. (Often used in syringe drivers).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Palliative supply.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Terminal restlessness/agitation, severe refractory nausea and vomiting in palliative care, severe pain adjunct.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The final step in palliative care when Midazolam or Haloperidol fail to settle terminal distress.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe cardiovascular disease, coma, concurrent severe CNS depressant overdose.", + "tags": [] + }, + { + "key": "Ambulatory Patients", + "val": "CRITICAL — Do not give to a patient expected to walk around the ward. They will collapse from hypotension.", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive hypotension with ANY blood pressure medication. Additive sedation with Opioids/Benzos.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Strict bed rest for 1-2 hours after an acute dose to prevent syncopal falls.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required in palliative settings.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Palliative Nuke", + "val": "When a dying patient is experiencing 'terminal anguish' (severe, uncontrollable thrashing, vomiting, and distress), a SC infusion of Levomepromazine provides unparalleled, deep tranquility and comfort. It is the ultimate drug for ensuring a peaceful death.", + "tags": [] + }, + { + "key": "The Syringe Driver", + "val": "Highly compatible with Morphine and Midazolam in a subcutaneous syringe driver, making it an excellent all-in-one palliative mix.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Broad multi-receptor antagonist. Weak D2 blockade (antipsychotic), massive Alpha-1 blockade (hypotension), massive H1 blockade (sedation), and strong muscarinic blockade. Also possesses unique mild analgesic properties.", + "tags": [] + }, + { + "key": "Onset", + "val": "**SC** 15-30 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "30 hours. Extensively hepatically metabolised.", + "tags": [] + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "FGA / Sedative — Also known as Methotrimeprazine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (25 mg, 100 mg). (Nozinan)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** or **SC** 6.25 - 12.5 mg q4-8h PRN. Or continuous SC syringe driver (25-100 mg/24h). Max **300 mg/day** (Usually 12.5 - 50 mg/day in palliative care)." + }, + { + "label": "Key Indication Doses", + "value": "Palliative Agitation / Nausea: **PO** or **SC** 6.25 - 12.5 mg q4-8h PRN. Or continuous SC syringe driver (25-100 mg/24h). Severe Acute Psychosis: **PO** 50-200 mg/day (Rarely used for this indication today). Elderly / Frail: Start at micro-doses (e.g., 3.125 mg to 6.25 mg)." + }, + { + "label": "Best Uses", + "value": "Levomepromazine is a highly sedating phenothiazine used in palliative care for refractory nausea and terminal agitation, but causes profound hypotension and sedation at higher doses." + }, + { + "label": "Avoid / Cautions", + "value": "Severe cardiovascular disease, coma, concurrent severe CNS depressant overdose." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Profound, fainting-level orthostatic hypotension. Reflex tachycardia, **QTc** prolongation. Neurological: Extreme sedation, lethargy, lowers seizure threshold. (Less EPS than Haloperidol due to strong anticholinergic properties). Gastrointestinal: Severe dry mouth, constipation." + }, + { + "label": "Key Interactions", + "value": "Additive hypotension with ANY blood pressure medication. Additive sedation with Opioids/Benzos." + }, + { + "label": "Monitoring", + "value": "Strict bed rest for 1-2 hours after an acute dose to prevent syncopal falls. No specific routine laboratory tests required in palliative settings." + }, + { + "label": "Clinical Pearl", + "value": "When a dying patient is experiencing 'terminal anguish' (severe, uncontrollable thrashing, vomiting, and distress), a SC infusion of Levomepromazine provides unparalleled, deep tranquility and comfort. It is the ultimate drug for ensuring a peaceful death." + } + ] + }, + { + "slug": "propranolol", + "name": "Propranolol", + "class": "Adjunct", + "subclass": "Beta-Blocker", + "category": "Psychiatry - Acute Calming & Sedation", + "accent": "#e11d48", + "tag": "BETA-BLOCKER", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "120 mg/day (Psych)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3-6 h", + "cls": "", + "flag": "" + }, + { + "label": "Asthma", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Akathisia", + "value": "1ST LINE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly lipophilic, non-selective beta-blocker. Crosses the blood-brain barrier easily. The absolute gold-standard treatment for antipsychotic-induced akathisia and performance anxiety.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **120 mg/day** (for anxiety/akathisia). Cardiac doses are higher.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Will cause lethal bronchospasm in asthmatics due to Beta-2 blockade in the lungs.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Propranolol is a non-selective beta-blocker for essential tremor, performance anxiety, and migraine prophylaxis, but is absolutely contraindicated in asthma and can mask hypoglycaemia symptoms in diabetics.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory", + "val": "CRITICAL — Bronchospasm (can trigger status asthmaticus).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Bradycardia, hypotension, cold extremities.", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Fatigue, vivid dreams, nightmares, depression (due to high CNS penetration).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Masks physiological signs of hypoglycemia (tremor, tachycardia) in diabetics.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Akathisia (Antipsychotic-induced)", + "val": "**PO** 10-20 mg **BD** to **TDS**. Titrate to response.", + "tags": [] + }, + { + "key": "Performance Anxiety", + "val": "**PO** 10-40 mg STAT, taken 60 mins before the triggering event.", + "tags": [] + }, + { + "key": "Essential Tremor / Thyrotoxicosis", + "val": "**PO** 40 mg **BD** to **TDS**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Deralin, Inderal", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10, 40 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** use (Rare, used in thyroid storm).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Migraine prophylaxis, essential tremor, performance anxiety, thyrotoxicosis, portal hypertension.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Akathisia, PTSD (fear-memory extinction).", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The most versatile non-cardiac beta-blocker in medicine due to its CNS penetration.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Asthma, 2nd/3rd degree heart block, severe bradycardia, cardiogenic shock.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C (Risk of fetal bradycardia).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Propranolol pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Non-DHP CCBs (Verapamil, Diltiazem) cause fatal heart block/asystole.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Adrenaline. If a patient on Propranolol is given Adrenaline, the Beta-2 receptors are blocked, leaving Alpha-1 unopposed, causing a massive, lethal hypertensive spike.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Check **HR** and **BP** before initiating. Do not give if HR < 55 bpm.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Akathisia Fix", + "val": "When a patient on Aripiprazole or Haloperidol is pacing the halls relentlessly (akathisia), Propranolol 10mg BD cures the restlessness within hours without sedating the patient. It is vastly superior to Diazepam for this indication.", + "tags": [] + }, + { + "key": "The Stage Fright Secret", + "val": "Propranolol does not alter cognition or make you sleepy. It simply stops the physical manifestations of panic (sweating, shaking hands, racing heart), tricking the brain into feeling calm. Widely used by surgeons and musicians.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Non-selective competitive antagonist at Beta-1 and Beta-2 adrenoceptors. Blocks peripheral sympathetic somatic symptoms (tremor, tachycardia) and centrally dampens anxiety/restlessness.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-6 hours (Requires multiple daily doses). Highly lipophilic.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - PROPRANOLOL-WGR ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Beta-Blocker — Highly lipophilic, non-selective beta-blocker." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10, 40 mg). (Deralin, Inderal)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10-20 mg **BD** to **TDS**. Titrate to response. Max **120 mg/day** (for anxiety/akathisia). Cardiac doses are higher." + }, + { + "label": "Key Indication Doses", + "value": "Akathisia (Antipsychotic-induced): **PO** 10-20 mg **BD** to **TDS**. Titrate to response. Performance Anxiety: **PO** 10-40 mg STAT, taken 60 mins before the triggering event. Essential Tremor / Thyrotoxicosis: **PO** 40 mg **BD** to **TDS**." + }, + { + "label": "Best Uses", + "value": "Propranolol is a non-selective beta-blocker for essential tremor, performance anxiety, and migraine prophylaxis, but is absolutely contraindicated in asthma and can mask hypoglycaemia symptoms in diabetics." + }, + { + "label": "Avoid / Cautions", + "value": "Asthma, 2nd/3rd degree heart block, severe bradycardia, cardiogenic shock. **Pregnancy** Category C (Risk of fetal bradycardia)." + }, + { + "label": "Key Risks", + "value": "Respiratory: Bronchospasm (can trigger status asthmaticus). Cardiovascular: Bradycardia, hypotension, cold extremities. Neurological: Fatigue, vivid dreams, nightmares, depression (due to high CNS penetration). Metabolic: Masks physiological signs of hypoglycemia (tremor, tachycardia) in diabetics." + }, + { + "label": "Key Interactions", + "value": "Non-DHP CCBs (Verapamil, Diltiazem) cause fatal heart block/asystole. Adrenaline. If a patient on Propranolol is given Adrenaline, the Beta-2 receptors are blocked, leaving Alpha-1 unopposed, causing a massive, lethal hypertensive spike." + }, + { + "label": "Monitoring", + "value": "Check **HR** and **BP** before initiating. Do not give if HR < 55 bpm. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "When a patient on Aripiprazole or Haloperidol is pacing the halls relentlessly (akathisia), Propranolol 10mg BD cures the restlessness within hours without sedating the patient. It is vastly superior to Diazepam for this indication." + } + ] + }, + { + "slug": "ziprasidone-im", + "name": "Ziprasidone IM", + "class": "Antipsychotic", + "subclass": "SGA / Benzisothiazolyl", + "category": "Psychiatry - Acute Calming & Sedation", + "accent": "#e11d48", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "40 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-5 h", + "cls": "", + "flag": "" + }, + { + "label": "QTc Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "RAPID", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Short-acting intramuscular formulation of Ziprasidone. Provides rapid sedation for acute agitation in schizophrenia/bipolar without the severe EPS risks of typical agents.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **40 mg/day** (e.g., 20 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "High baseline risk of QTc prolongation. Limit use to a maximum of 3 consecutive days before switching to oral.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ziprasidone IM is an injectable atypical antipsychotic for acute agitation with low metabolic risk, but has the highest QTc prolongation risk of IM antipsychotics requiring ECG monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — **QTc** prolongation. HIGH — Orthostatic hypotension, tachycardia.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "HIGH — Somnolence, dizziness, akathisia.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Nausea (food not required for the IM formulation, unlike the oral capsules).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Agitation", + "val": "**IM** 10-20 mg STAT. May repeat 10 mg after 2 hours, or 20 mg after 4 hours. Max 40 mg/day.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Max 10 mg STAT. Extreme caution due to orthostatic drops.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zeldox IM", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials (20 mg powder for reconstitution). MUST be injected deep **IM**. Never give IV.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital psychiatric supply. S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Rapid control of acute agitation in schizophrenia.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Alternative to IM Olanzapine or Haloperidol when a patient is highly prone to EPS or when benzodiazepines are contraindicated.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Recent myocardial infarction, uncompensated heart failure, baseline **QTc** > 500 ms.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 500 + } + }, + "note": "Ziprasidone IM absolute contraindication row uses QTc >500 ms; lower QTc prolongation remains a caution/monitoring prompt elsewhere." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Ziprasidone IM pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Avoid concurrent use of other QTc prolonging drugs (e.g., Droperidol, Amiodarone, Macrolides).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive hypotension with antihypertensives.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG** to measure QTc interval before administration if clinically feasible.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "Check **BP** for postural drops after injection. Keep patient seated or supine.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 3-Day Limit", + "val": "IM Ziprasidone is exclusively a short-term bridge. Guidelines mandate capping its use at 3 consecutive days to prevent cumulative cardiovascular toxicity. Transition to oral therapy ASAP.", + "tags": [] + }, + { + "key": "Food Independent", + "val": "Unlike oral Ziprasidone (which fails to absorb without a 500-calorie meal), the IM injection bypasses the gut entirely and works flawlessly on a fasting/refusing patient.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "D2 and 5-HT2A antagonist. Rapid systemic absorption from muscle tissue provides intense sedation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IM** 15-30 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-5 hours. (Shorter than the oral formulation).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ZELDOX IM ARTG/PI and PBS search checked 2026-05-12 for sedative/acute-calming batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Benzisothiazolyl — Short-acting intramuscular formulation of Ziprasidone." + }, + { + "label": "Route / Formulation", + "value": "Vials (20 mg powder for reconstitution). MUST be injected deep **IM**. Never give IV. (Zeldox IM)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 10-20 mg STAT. May repeat 10 mg after 2 hours, or 20 mg after 4 hours. Max 40 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Acute Agitation: **IM** 10-20 mg STAT. May repeat 10 mg after 2 hours, or 20 mg after 4 hours. Max 40 mg/day. Elderly / Frail: Max 10 mg STAT. Extreme caution due to orthostatic drops." + }, + { + "label": "Best Uses", + "value": "Ziprasidone IM is an injectable atypical antipsychotic for acute agitation with low metabolic risk, but has the highest QTc prolongation risk of IM antipsychotics requiring ECG monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Recent myocardial infarction, uncompensated heart failure, baseline **QTc** > 500 ms. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: **QTc** prolongation. HIGH — Orthostatic hypotension, tachycardia. Neurological: Somnolence, dizziness, akathisia. Gastrointestinal: Nausea (food not required for the IM formulation, unlike the oral capsules)." + }, + { + "label": "Key Interactions", + "value": "Avoid concurrent use of other QTc prolonging drugs (e.g., Droperidol, Amiodarone, Macrolides). Additive hypotension with antihypertensives." + }, + { + "label": "Monitoring", + "value": "Baseline **ECG** to measure QTc interval before administration if clinically feasible. Check **BP** for postural drops after injection. Keep patient seated or supine." + }, + { + "label": "Clinical Pearl", + "value": "IM Ziprasidone is exclusively a short-term bridge. Guidelines mandate capping its use at 3 consecutive days to prevent cumulative cardiovascular toxicity. Transition to oral therapy ASAP." + } + ] + }, + { + "slug": "agomelatine", + "name": "Agomelatine", + "class": "Antidepressant", + "subclass": "MT1/MT2 Agonist + 5HT2C Ant", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "MELATONERGIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "50 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1-2 h", + "cls": "", + "flag": "" + }, + { + "label": "Hepatotoxicity", + "value": "MONITOR LFTs", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "MILD", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Unique 'melatonergic' antidepressant. Re-syncs the circadian rhythm to improve sleep and mood. Devoid of sexual side effects, weight gain, or withdrawal syndromes. Highly liver toxic.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **50 mg/day** (strictly at bedtime).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Mandatory rigid liver function testing. You cannot prescribe this drug if the patient refuses blood tests.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Agomelatine is a unique melatonergic antidepressant with no sexual dysfunction or weight gain, but requires mandatory liver function monitoring due to hepatotoxicity risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Hepatic", + "val": "CRITICAL — Hepatotoxicity, severe transaminitis, fatal liver failure (Rare, but idiosyncratic and highly dangerous).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "LOW — Dizziness, somnolence, headache.", + "tags": [] + }, + { + "key": "Endocrine/Metabolic", + "val": "SAFE — Zero sexual dysfunction. Weight neutral. Zero withdrawal syndrome.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Major Depressive Disorder", + "val": "**PO** 25 mg **NOCTE**. If inadequate response after 2 weeks, increase to Max 50 mg **NOCTE**.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "CRITICAL — Absolute contraindication in any form of liver impairment or transaminitis.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Valdoxan", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (25 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Private script only. Not PBS listed in Australia (Expensive out-of-pocket).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Chosen when patients completely refuse SSRIs due to sexual dysfunction or weight gain, and can afford private scripts.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Any hepatic impairment (e.g., cirrhosis, active hepatitis), transaminases > 3x normal limit. Concurrent use of potent CYP1A2 inhibitors (Fluvoxamine, Ciprofloxacin).", + "tags": [], + "patient": { + "factors": ["hepatic", "allergy-fluoro"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Elderly", + "val": "CAUTION — Efficacy not established in patients > 75 years.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Agomelatine pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Fluvoxamine and Ciprofloxacin inhibit CYP1A2, skyrocketing Agomelatine blood levels and guaranteeing liver damage. AVOID.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Smoking induces CYP1A2, significantly dropping blood levels. If patient stops smoking, levels will spike.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **LFTs** must be performed at Baseline, Week 3, Week 6, Week 12, and Month 6. Stop immediately if ALT/AST > 3x normal limit.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Warn patient to report dark urine, pale stool, or yellow sclera immediately.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Liver Rule", + "val": "Do not write the first script without holding a baseline normal LFT result in your hand. If they drink heavily, choose a different drug.", + "tags": [] + }, + { + "key": "The Clean Stop", + "val": "Unlike SSRIs or Venlafaxine, Agomelatine has zero discontinuation syndrome. A patient can stop taking 50mg cold-turkey without any 'brain zaps' or withdrawal.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Agonist at Melatonin (MT1 and MT2) receptors, resetting the sleep-wake cycle. Antagonist at Serotonin 5-HT2C receptors in the frontal cortex, releasing dopamine and noradrenaline to boost mood.", + "tags": [] + }, + { + "key": "Onset", + "val": "Sleep improves in days. Mood improves in 2-4 weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-2 hours. Heavily metabolised by CYP1A2.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - VALDOXAN/VALOMEL Australian PI, TGA ARTG 159712, and PBS non-listing search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "MT1/MT2 Agonist + 5HT2C Ant — Unique 'melatonergic' antidepressant." + }, + { + "label": "Route / Formulation", + "value": "Tablets (25 mg). (Valdoxan)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 25 mg **NOCTE**. If inadequate response after 2 weeks, increase to Max 50 mg **NOCTE**." + }, + { + "label": "Key Indication Doses", + "value": "Major Depressive Disorder: **PO** 25 mg **NOCTE**. If inadequate response after 2 weeks, increase to Max 50 mg **NOCTE**. Hepatic Impairment: Absolute contraindication in any form of liver impairment or transaminitis." + }, + { + "label": "Best Uses", + "value": "Agomelatine is a unique melatonergic antidepressant with no sexual dysfunction or weight gain, but requires mandatory liver function monitoring due to hepatotoxicity risk." + }, + { + "label": "Avoid / Cautions", + "value": "Any hepatic impairment (e.g., cirrhosis, active hepatitis), transaminases > 3x normal limit. Concurrent use of potent CYP1A2 inhibitors (Fluvoxamine, Ciprofloxacin). **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Hepatic: Hepatotoxicity, severe transaminitis, fatal liver failure (Rare, but idiosyncratic and highly dangerous). Neurological: Dizziness, somnolence, headache. Endocrine/Metabolic: Zero sexual dysfunction. Weight neutral. Zero withdrawal syndrome." + }, + { + "label": "Key Interactions", + "value": "Fluvoxamine and Ciprofloxacin inhibit CYP1A2, skyrocketing Agomelatine blood levels and guaranteeing liver damage. AVOID. Smoking induces CYP1A2, significantly dropping blood levels. If patient stops smoking, levels will spike." + }, + { + "label": "Monitoring", + "value": "**LFTs** must be performed at Baseline, Week 3, Week 6, Week 12, and Month 6. Stop immediately if ALT/AST > 3x normal limit. Warn patient to report dark urine, pale stool, or yellow sclera immediately." + }, + { + "label": "Clinical Pearl", + "value": "Do not write the first script without holding a baseline normal LFT result in your hand. If they drink heavily, choose a different drug." + } + ] + }, + { + "slug": "amitriptyline", + "name": "Amitriptyline", + "class": "Antidepressant", + "subclass": "TCA", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "TCA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "150 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "20 h", + "cls": "", + "flag": "" + }, + { + "label": "Toxicity in OD", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Anticholinergic", + "value": "SEVERE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Tricyclic Antidepressant (TCA). The original, 'dirty' but incredibly effective drug. Used rarely for depression now, but heavily utilized in micro-doses for chronic nerve pain and migraine prevention.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **150 mg/day** (Depression). Max 50-75 mg/day (Neuropathic pain).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Fatal in overdose. TCAs block cardiac sodium channels causing widening QRS, lethal arrhythmias, and profound anticholinergic coma.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Amitriptyline is a TCA widely used at low dose for neuropathic pain, migraine prophylaxis, and insomnia, but is cardiotoxic in overdose and has significant anticholinergic burden in elderly.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — **QTc** prolongation, QRS widening, orthostatic hypotension, tachycardia. Fatal arrhythmias in overdose.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "HIGH — Profound morning hangover/sedation, delirium (especially elderly), lowers seizure threshold.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe dry mouth, severe constipation, urinary retention (Anticholinergic toxidrome).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Weight gain (H1 blockade).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Neuropathic Pain / Migraine", + "val": "Start **PO** 10-25 mg **NOCTE**. Titrate up every 1-2 weeks. Target 25-75 mg NOCTE.", + "tags": [] + }, + { + "key": "Depression", + "val": "Start **PO** 50 mg **NOCTE**. Titrate to 100-150 mg/day. (Rarely used due to safer SSRIs).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Avoid if possible. If required, strictly max 10 mg NOCTE due to severe falls/delirium risk.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Endep", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg, 25 mg, 50 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Neuropathic pain, migraine prophylaxis, IBS-D, severe insomnia.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "First-line low-dose adjunct for chronic nerve pain (e.g., post-herpetic neuralgia, diabetic neuropathy).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Recent myocardial infarction, heart block, severe hepatic impairment, concurrent MAOIs.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Elderly", + "val": "CRITICAL — Heavily featured on the Beers Criteria. Causes falls, confusion, and urinary retention. Use Nortriptyline instead if a TCA is required.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Amitriptyline pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs, Tramadol (Serotonin Syndrome).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive anticholinergic burden (Oxybutynin, Promethazine).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (Fluoxetine, Paroxetine) spike TCA blood levels into the toxic range.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG** (Check QTc and QRS width) before escalating doses.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "Monitor for urinary retention and severe constipation.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Overdose Antidote", + "val": "If a patient overdoses on Amitriptyline, their QRS will widen on the ECG. You MUST push IV Sodium Bicarbonate. It overwhelms the sodium channel blockade and saves the heart.", + "tags": [] + }, + { + "key": "Take Early", + "val": "To avoid the brutal 'morning hangover', tell patients to take their dose at 7 PM or 8 PM, not right before bed at 11 PM.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits reuptake of Serotonin and Noradrenaline. Also heavily blocks Histamine (H1), Muscarinic (M1), and Alpha-1 adrenergic receptors, driving its massive side effect profile.", + "tags": [] + }, + { + "key": "Onset", + "val": "Sedation is immediate. Pain relief takes 2-4 weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10-28 hours. Metabolised by CYP2D6/CYP2C19 to active nortriptyline.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ENDEP Australian PI/CMI, ARTG 71044/59788/64425, and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "TCA — Tricyclic Antidepressant (TCA)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg, 25 mg, 50 mg). (Endep)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 10-25 mg **NOCTE**. Titrate up every 1-2 weeks. Target 25-75 mg NOCTE. Max **150 mg/day** (Depression)." + }, + { + "label": "Key Indication Doses", + "value": "Neuropathic Pain / Migraine: Start **PO** 10-25 mg **NOCTE**. Titrate up every 1-2 weeks. Target 25-75 mg NOCTE. Depression: Start **PO** 50 mg **NOCTE**. Titrate to 100-150 mg/day. (Rarely used due to safer SSRIs). Elderly / Frail: Avoid if possible. If required, strictly max 10 mg NOCTE due to severe falls/delirium risk." + }, + { + "label": "Best Uses", + "value": "Amitriptyline is a TCA widely used at low dose for neuropathic pain, migraine prophylaxis, and insomnia, but is cardiotoxic in overdose and has significant anticholinergic burden in elderly." + }, + { + "label": "Avoid / Cautions", + "value": "Recent myocardial infarction, heart block, severe hepatic impairment, concurrent MAOIs. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: **QTc** prolongation, QRS widening, orthostatic hypotension, tachycardia. Fatal arrhythmias in overdose. Neurological: Profound morning hangover/sedation, delirium (especially elderly), lowers seizure threshold. Gastrointestinal: Severe dry mouth, severe constipation, urinary retention (Anticholinergic toxidrome). Metabolic: Weight gain (H1 blockade)." + }, + { + "label": "Key Interactions", + "value": "MAOIs, Tramadol (Serotonin Syndrome). Additive anticholinergic burden (Oxybutynin, Promethazine). **CYP2D6** inhibitors (Fluoxetine, Paroxetine) spike TCA blood levels into the toxic range." + }, + { + "label": "Monitoring", + "value": "Baseline **ECG** (Check QTc and QRS width) before escalating doses. Monitor for urinary retention and severe constipation." + }, + { + "label": "Clinical Pearl", + "value": "If a patient overdoses on Amitriptyline, their QRS will widen on the ECG. You MUST push IV Sodium Bicarbonate. It overwhelms the sodium channel blockade and saves the heart." + } + ] + }, + { + "slug": "citalopram", + "name": "Citalopram", + "class": "Antidepressant", + "subclass": "SSRI", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "SSRI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "40 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "35 h", + "cls": "", + "flag": "" + }, + { + "label": "QTc Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Elderly Max", + "value": "20 mg/day", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Racemic SSRI. Very effective and highly tolerable, but strictly dose-capped worldwide due to a high, dose-dependent risk of fatal QTc prolongation.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **40 mg/day** (Adults) • Max **20 mg/day** (Elderly >65 yrs).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Do not exceed 20 mg in the elderly. Historically, doses of 60mg were used, but this is now heavily contraindicated due to sudden cardiac death.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Citalopram is an SSRI for depression and anxiety disorders, but has a dose-dependent QTc prolongation risk with a maximum dose of 40 mg/day (20 mg in elderly).", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Dose-dependent **QTc** prolongation, potentially leading to Torsades de Pointes. (Highest risk among all SSRIs).", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Metabolic", + "val": "HIGH — Hyponatremia (SIADH) in the elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea, dry mouth.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Depression / Anxiety", + "val": "Start **PO** 20 mg **OD**. May increase to Max 40 mg/day after 2-4 weeks.", + "tags": [] + }, + { + "key": "Elderly / Hepatic Impairment", + "val": "MANDATORY — Max **PO** 20 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Celapram, Cipramil", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (20 mg, 40 mg). Oral liquid.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder, Panic Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line SSRI option, though increasingly superseded by Escitalopram (which isolates the active S-enantiomer and has a slightly better safety profile).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL - Baseline prolonged QTc or congenital long QT syndrome, concurrent MAOI use, or medicines known to prolong QTc without specialist review.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 500 + } + }, + "note": "Citalopram PI/source review supports avoiding significant QT prolongation risk; ECG review is needed before dose escalation." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Citalopram pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Avoid mixing with other QTc prolonging drugs (e.g., Amiodarone, Haloperidol, Sotalol).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Omeprazole inhibits CYP2C19, spiking Citalopram levels. Max dose is 20mg if on Omeprazole.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG** to check QTc before escalating to 40 mg, or in any patient > 60 years.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Laboratory", + "val": "MANDATORY — Check **U&E** (sodium) at 2-4 weeks in the elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Racemic Burden", + "val": "Citalopram contains 50% inactive 'R' enantiomer. This inactive half does not help depression, but it DOES block the heart's potassium channels, causing the QTc prolongation. Switching to Escitalopram removes this 'R' garbage, lowering the cardiac risk.", + "tags": [] + }, + { + "key": "The Hyponatremia Risk", + "val": "If an elderly woman on Citalopram presents with sudden confusion, lethargy, or falls, check her Sodium. SSRI-induced SIADH is extremely common and easily missed.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selective inhibition of serotonin reuptake (SERT). Exists as a 50:50 racemic mixture of R- and S-enantiomers. (Only the S-enantiomer works on serotonin; the R-enantiomer causes side effects).", + "tags": [] + }, + { + "key": "Onset", + "val": "2-6 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "35 hours. Metabolised by CYP2C19 and CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CELAPRAM Australian PI/CMI, ARTG 82904, and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SSRI — Racemic SSRI." + }, + { + "label": "Route / Formulation", + "value": "Tablets (20 mg, 40 mg). Oral liquid. (Celapram, Cipramil)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 20 mg **OD**. May increase to Max 40 mg/day after 2-4 weeks." + }, + { + "label": "Key Indication Doses", + "value": "Depression / Anxiety: Start **PO** 20 mg **OD**. May increase to Max 40 mg/day after 2-4 weeks. Elderly / Hepatic Impairment: Max **PO** 20 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Citalopram is an SSRI for depression and anxiety disorders, but has a dose-dependent QTc prolongation risk with a maximum dose of 40 mg/day (20 mg in elderly)." + }, + { + "label": "Avoid / Cautions", + "value": "Baseline **QTc** > 500 ms, concurrent MAOI use. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Dose-dependent **QTc** prolongation, potentially leading to Torsades de Pointes. (Highest risk among all SSRIs). Metabolic: Hyponatremia (SIADH) in the elderly. Gastrointestinal: Nausea, dry mouth." + }, + { + "label": "Key Interactions", + "value": "Avoid mixing with other QTc prolonging drugs (e.g., Amiodarone, Haloperidol, Sotalol). Omeprazole inhibits CYP2C19, spiking Citalopram levels. Max dose is 20mg if on Omeprazole." + }, + { + "label": "Monitoring", + "value": "Baseline **ECG** to check QTc before escalating to 40 mg, or in any patient > 60 years. Check **U&E** (sodium) at 2-4 weeks in the elderly." + }, + { + "label": "Clinical Pearl", + "value": "Citalopram contains 50% inactive 'R' enantiomer. This inactive half does not help depression, but it DOES block the heart's potassium channels, causing the QTc prolongation. Switching to Escitalopram removes this 'R' garbage, lowering the cardiac risk." + } + ] + }, + { + "slug": "clomipramine", + "name": "Clomipramine", + "class": "Antidepressant", + "subclass": "TCA", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "TCA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "250 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "32 h", + "cls": "", + "flag": "" + }, + { + "label": "Seizure Risk", + "value": "HIGH", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Serotonin", + "value": "VERY POTENT", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Tricyclic Antidepressant (TCA) with unparalleled potency for serotonin reuptake inhibition. The absolute gold-standard, most effective drug in the world for severe Obsessive-Compulsive Disorder (OCD).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **250 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly toxic in overdose. Lowers the seizure threshold significantly more than other TCAs. Causes intense anticholinergic side effects.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Clomipramine is the most serotonergic TCA and gold-standard pharmacotherapy for severe OCD, but has significant anticholinergic effects, seizure risk, and is dangerous in overdose.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Dose-dependent seizures (Highest risk of all antidepressants at doses > 250mg). HIGH — Sedation, tremor, delirium.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CRITICAL — Fatal arrhythmias in overdose, QRS widening, **QTc** prolongation, postural hypotension.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe dry mouth, intense constipation, urinary retention.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Obsessive-Compulsive Disorder", + "val": "Start **PO** 25 mg **NOCTE**. Titrate slowly to 100-250 mg/day. (Requires massive doses to break OCD loops).", + "tags": [] + }, + { + "key": "Depression / Cataplexy", + "val": "**PO** 25-75 mg/day.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Start at 10 mg. High risk of falls, delirium, and heart block.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Anafranil", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (25 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Obsessive-Compulsive Disorder (OCD), Major Depressive Disorder, Cataplexy associated with narcolepsy.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Reserved for severe, treatment-resistant OCD that has failed high-dose SSRIs (like Fluvoxamine or Sertraline).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Recent myocardial infarction, arrhythmias, concurrent MAOIs (causes instantly fatal Serotonin Syndrome).", + "tags": [] + }, + { + "key": "Neurological", + "val": "CAUTION — History of epilepsy or brain trauma (seizure risk).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Clomipramine pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — SSRIs, Tramadol, MAOIs (Extreme risk of fatal Serotonin Syndrome).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (Fluoxetine, Paroxetine) spike Clomipramine levels into the lethal seizure range.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline and routine **ECG** (monitoring QTc and QRS) before exceeding 150 mg/day.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "Ensure rigorous bowel management (laxatives) to prevent impaction.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Orgasm Phenomenon", + "val": "Clomipramine uniquely causes a highly bizarre, rare side effect: spontaneous orgasms when yawning. While it sounds amusing, it is deeply distressing for the patient.", + "tags": [] + }, + { + "key": "The Lethal Swap", + "val": "If a patient is failing Fluoxetine and the psychiatrist switches them to Clomipramine, you MUST wait 5 weeks for the Fluoxetine to wash out. Fluoxetine blocks CYP2D6 for a month; if you start Clomipramine early, it builds up and kills the patient via seizures/arrhythmia.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits reuptake of serotonin (highly selective parent drug) and noradrenaline (via its active metabolite desmethylclomipramine). Heavy blockade of H1, M1, and Alpha-1 receptors.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-6 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "32 hours. Active metabolite has a half-life of ~70 hours. Metabolised by CYP2D6/CYP1A2.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - PLACIL Australian CMI/ARTG 143879 and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "TCA — Tricyclic Antidepressant (TCA) with unparalleled potency for serotonin reuptake inhibition." + }, + { + "label": "Route / Formulation", + "value": "Tablets (25 mg). (Anafranil)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 25 mg **NOCTE**. Titrate slowly to 100-250 mg/day. (Requires massive doses to break OCD loops). Max **250 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Obsessive-Compulsive Disorder: Start **PO** 25 mg **NOCTE**. Titrate slowly to 100-250 mg/day. (Requires massive doses to break OCD loops). Depression / Cataplexy: **PO** 25-75 mg/day. Elderly / Frail: Start at 10 mg. High risk of falls, delirium, and heart block." + }, + { + "label": "Best Uses", + "value": "Clomipramine is the most serotonergic TCA and gold-standard pharmacotherapy for severe OCD, but has significant anticholinergic effects, seizure risk, and is dangerous in overdose." + }, + { + "label": "Avoid / Cautions", + "value": "Recent myocardial infarction, arrhythmias, concurrent MAOIs (causes instantly fatal Serotonin Syndrome). **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Dose-dependent seizures (Highest risk of all antidepressants at doses > 250mg). HIGH — Sedation, tremor, delirium. Cardiovascular: Fatal arrhythmias in overdose, QRS widening, **QTc** prolongation, postural hypotension. Gastrointestinal: Severe dry mouth, intense constipation, urinary retention." + }, + { + "label": "Key Interactions", + "value": "SSRIs, Tramadol, MAOIs (Extreme risk of fatal Serotonin Syndrome). **CYP2D6** inhibitors (Fluoxetine, Paroxetine) spike Clomipramine levels into the lethal seizure range." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **ECG** (monitoring QTc and QRS) before exceeding 150 mg/day. Ensure rigorous bowel management (laxatives) to prevent impaction." + }, + { + "label": "Clinical Pearl", + "value": "Clomipramine uniquely causes a highly bizarre, rare side effect: spontaneous orgasms when yawning. While it sounds amusing, it is deeply distressing for the patient." + } + ] + }, + { + "slug": "desvenlafaxine", + "name": "Desvenlafaxine", + "class": "Antidepressant", + "subclass": "SNRI", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "SNRI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "200 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "11 h", + "cls": "", + "flag": "" + }, + { + "label": "CYP Metabolism", + "value": "MINIMAL", + "cls": "good", + "flag": "" + }, + { + "label": "Hypertension", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The active major metabolite of Venlafaxine. Bypasses the need for liver CYP2D6 activation. Provides highly predictable blood levels and avoids the drug interactions of standard Venlafaxine.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **200 mg/day** (though doses > 50 mg rarely provide extra psychiatric benefit, just more side effects).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Cleared almost entirely by the kidneys. Avoid in severe renal failure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Desvenlafaxine is the active metabolite of venlafaxine with simpler dosing and fewer drug interactions, but offers no clear efficacy advantage and shares the same discontinuation syndrome.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, dry mouth, constipation.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Insomnia, dizziness, hyperhidrosis (severe sweating). Discontinuation syndrome (brain zaps).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Hypertension, tachycardia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Major Depressive Disorder", + "val": "**PO** 50 mg **OD**. May increase to 100 mg/day if needed, but 50 mg is the standard therapeutic dose.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** 30-50, Max 50 mg/day. If **eGFR** < 30, give 50 mg EVERY OTHER DAY.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Pristiq", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Extended Release (ER) Tablets (50 mg, 100 mg). Do NOT crush. Empty ghost tablet will pass in stool.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder (MDD).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Vasomotor symptoms (hot flushes) in menopause.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Preferred over Venlafaxine for patients taking multiple medications (due to zero CYP interactions) or known CYP2D6 poor metabolizers.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent MAOI use.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Desvenlafaxine pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs, Tramadol, St John's Wort (Serotonin Syndrome).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "SAFE — Unlike Venlafaxine, it has zero significant CYP450 interactions, making it highly safe to mix with Tamoxifen, Statins, or heart meds.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **BP** prior to starting and regularly during therapy.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** (Requires good kidney function to clear).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Flat Dose Curve", + "val": "In clinical trials, 50 mg of Desvenlafaxine worked just as well as 100 mg or 200 mg for depression, but higher doses had double the side effects. Resist the urge to up-titrate rapidly if 50 mg fails; switch drugs instead.", + "tags": [] + }, + { + "key": "The Menopause Hack", + "val": "Low-dose Desvenlafaxine is highly effective at stopping hot flushes in women undergoing chemotherapy for breast cancer (who cannot take estrogen HRT).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "SNRI. Inhibits both serotonin and noradrenaline reuptake transporters.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-6 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "11 hours. Does NOT require CYP450 metabolism. Excreted 45% unchanged in urine, the rest conjugated.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - PRISTIQ Australian PI/CMI, ARTG 227804, and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SNRI — The active major metabolite of Venlafaxine." + }, + { + "label": "Route / Formulation", + "value": "Extended Release (ER) Tablets (50 mg, 100 mg). Do NOT crush. Empty ghost tablet will pass in stool. (Pristiq)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 50 mg **OD**. May increase to 100 mg/day if needed, but 50 mg is the standard therapeutic dose. Max **200 mg/day** (though doses > 50 mg rarely provide extra psychiatric benefit, just more side effects)." + }, + { + "label": "Key Indication Doses", + "value": "Major Depressive Disorder: **PO** 50 mg **OD**. May increase to 100 mg/day if needed, but 50 mg is the standard therapeutic dose. Renal Impairment: If **eGFR** 30-50, Max 50 mg/day. If **eGFR** < 30, give 50 mg EVERY OTHER DAY." + }, + { + "label": "Best Uses", + "value": "Desvenlafaxine is the active metabolite of venlafaxine with simpler dosing and fewer drug interactions, but offers no clear efficacy advantage and shares the same discontinuation syndrome." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent MAOI use. **Pregnancy** Category B2." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea, dry mouth, constipation. Neurological: Insomnia, dizziness, hyperhidrosis (severe sweating). Discontinuation syndrome (brain zaps). Cardiovascular: Hypertension, tachycardia." + }, + { + "label": "Key Interactions", + "value": "MAOIs, Tramadol, St John's Wort (Serotonin Syndrome). Unlike Venlafaxine, it has zero significant CYP450 interactions, making it highly safe to mix with Tamoxifen, Statins, or heart meds." + }, + { + "label": "Monitoring", + "value": "Monitor **BP** prior to starting and regularly during therapy. Check **eGFR** (Requires good kidney function to clear)." + }, + { + "label": "Clinical Pearl", + "value": "In clinical trials, 50 mg of Desvenlafaxine worked just as well as 100 mg or 200 mg for depression, but higher doses had double the side effects. Resist the urge to up-titrate rapidly if 50 mg fails; switch drugs instead." + } + ] + }, + { + "slug": "dosulepin", + "name": "Dosulepin", + "class": "Antidepressant", + "subclass": "TCA", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "TCA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "225 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "11-24 h", + "cls": "", + "flag": "" + }, + { + "label": "Toxicity in OD", + "value": "FATAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Anticholinergic", + "value": "HIGH", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Tricyclic Antidepressant (also known as Dothiepin). Historically popular but now considered the most dangerous TCA in overdose due to profound cardiac toxicity.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **225 mg/day** (Usually 75-150 mg NOCTE).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Do not initiate. TGA guidelines actively discourage prescribing Dosulepin due to the unacceptably narrow margin between therapeutic dose and fatal overdose.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dosulepin is a TCA with no advantages over other antidepressants but the highest lethality in overdose of all TCAs, and should generally be avoided in new prescriptions.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Massive QRS widening, ventricular fibrillation, and heart block in overdose. Extreme orthostatic hypotension.", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Lowers seizure threshold significantly more than other TCAs. HIGH — Sedation, delirium.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe dry mouth, constipation, urinary retention.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Depression", + "val": "**PO** 75-150 mg **NOCTE**. Max 225 mg/day.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Avoid. High risk of falls, delirium, and sudden cardiac death.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Prothiaden, Dothep", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets (25 mg, 75 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Actively restricted.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Obsolete. Only used in patients who have been stabilized on it for decades and refuse to cross-taper to safer agents.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Recent myocardial infarction, heart block, concurrent MAOIs, narrow-angle glaucoma, history of epilepsy.", + "tags": [] + }, + { + "key": "Suicide Risk", + "val": "CRITICAL — NEVER prescribe to a suicidal patient. A 10-day supply is easily fatal.", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs, Tramadol (Serotonin Syndrome). Additive CNS depression with alcohol.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — CYP2D6 inhibitors (Fluoxetine, Paroxetine) spike levels into the lethal range.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline and routine **ECG** (monitoring QTc and QRS width) is absolutely essential.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "Actively attempt to cross-taper the patient to an SSRI or Nortriptyline if they are admitted to the ward.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Lethal Index", + "val": "Of all the TCAs (which are already dangerous), Dosulepin has the highest toxicity index. The gap between a dose that fixes depression and a dose that stops the heart is frighteningly small.", + "tags": [] + }, + { + "key": "The Bicarbonate Rescue", + "val": "As with all TCAs, if a patient overdoses on Dosulepin and their QRS widens on the ECG, the immediate life-saving antidote is pushing rapid IV Sodium Bicarbonate to overcome the sodium channel blockade.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits reuptake of Serotonin and Noradrenaline. Strong blockade of H1, M1, and Alpha-1 receptors.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-6 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "11-24 hours. Active metabolite (northiaden) lasts longer.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DOTHEP/Dosulepin Australian PI/CMI, ARTG 34419/62910, and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "TCA — Tricyclic Antidepressant (also known as Dothiepin)." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets (25 mg, 75 mg). (Prothiaden, Dothep)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 75-150 mg **NOCTE**. Max 225 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Depression: **PO** 75-150 mg **NOCTE**. Max 225 mg/day. Elderly / Frail: Avoid. High risk of falls, delirium, and sudden cardiac death." + }, + { + "label": "Best Uses", + "value": "Dosulepin is a TCA with no advantages over other antidepressants but the highest lethality in overdose of all TCAs, and should generally be avoided in new prescriptions." + }, + { + "label": "Avoid / Cautions", + "value": "Recent myocardial infarction, heart block, concurrent MAOIs, narrow-angle glaucoma, history of epilepsy." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Massive QRS widening, ventricular fibrillation, and heart block in overdose. Extreme orthostatic hypotension. Neurological: Lowers seizure threshold significantly more than other TCAs. HIGH — Sedation, delirium. Gastrointestinal: Severe dry mouth, constipation, urinary retention." + }, + { + "label": "Key Interactions", + "value": "MAOIs, Tramadol (Serotonin Syndrome). Additive CNS depression with alcohol. CYP2D6 inhibitors (Fluoxetine, Paroxetine) spike levels into the lethal range." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **ECG** (monitoring QTc and QRS width) is absolutely essential. Actively attempt to cross-taper the patient to an SSRI or Nortriptyline if they are admitted to the ward." + }, + { + "label": "Clinical Pearl", + "value": "Of all the TCAs (which are already dangerous), Dosulepin has the highest toxicity index. The gap between a dose that fixes depression and a dose that stops the heart is frighteningly small." + } + ] + }, + { + "slug": "doxepin", + "name": "Doxepin", + "class": "Antidepressant", + "subclass": "TCA", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "TCA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "17 h", + "cls": "", + "flag": "" + }, + { + "label": "H1 Blockade", + "value": "EXTREME", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Insomnia", + "value": "OFF-LABEL", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Tricyclic Antidepressant. Possesses the absolute strongest H1-antihistamine receptor binding affinity of any drug in psychiatry. Used in micro-doses as a powerful sleeping pill and anti-itch medication.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg/day** (Depression). Max **10-50 mg/day** (Insomnia/Pruritus).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly sedating. Must be taken exactly at bedtime.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Doxepin is a TCA used at low dose for insomnia and at high dose for depression, but has potent antihistaminic sedation and is dangerous in overdose.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Profound next-day hangover, lethargy, delirium, cognitive blunting. Lowers seizure threshold.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Dry mouth, severe constipation.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CRITICAL — Fatal in overdose (arrhythmias). Orthostatic hypotension.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Depression", + "val": "Start **PO** 50-75 mg **NOCTE**. Titrate up to 300 mg/day.", + "tags": [] + }, + { + "key": "Insomnia / Severe Pruritus (Off-Label)", + "val": "**PO** 10-25 mg **NOCTE**.", + "tags": [] + }, + { + "key": "Elderly", + "val": "MANDATORY — Max 10-25 mg/day (High risk of morning hangover and falls).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Sinequan, Deptran", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (10, 25, 50 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Refractory insomnia, chronic idiopathic urticaria, severe neuropathic itch.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Obsolete for depression. First-line rescue agent for dermatologists treating ungodly, whole-body chronic itching that fails standard antihistamines.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Recent MI, heart block, severe BPH/urinary retention, concurrent MAOIs.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Doxepin pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive severe CNS depression with Opioids, Benzos, and Alcohol.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (Paroxetine) drastically spike Doxepin levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG** before treating depression (High doses).", + "tags": [] + }, + { + "key": "Bedside", + "val": "Warn the patient not to drive the morning after their first dose due to the massive hangover effect.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Itch Nuke", + "val": "When a patient has end-stage renal failure or severe liver disease, they often develop a relentless, maddening whole-body itch (uremic/hepatic pruritus). Standard antihistamines do nothing. A tiny 10mg dose of Doxepin at night often cures the itch entirely and lets them sleep.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits serotonin and noradrenaline reuptake. However, its affinity for the H1 histamine receptor is ~800 times stronger than diphenhydramine (Benadryl), making it the ultimate central antihistamine.", + "tags": [] + }, + { + "key": "Onset", + "val": "Sedation/Itch relief is immediate. Depression takes 2-4 weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "17 hours (Active metabolite nordoxepin lasts 50 hours, causing severe hangover).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - DEPTRAN Australian PI/CMI, ARTG 308999, and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "TCA — Tricyclic Antidepressant." + }, + { + "label": "Route / Formulation", + "value": "Capsules (10, 25, 50 mg). (Sinequan, Deptran)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 50-75 mg **NOCTE**. Titrate up to 300 mg/day. Max **300 mg/day** (Depression)." + }, + { + "label": "Key Indication Doses", + "value": "Depression: Start **PO** 50-75 mg **NOCTE**. Titrate up to 300 mg/day. Insomnia / Severe Pruritus (Off-Label): **PO** 10-25 mg **NOCTE**. Elderly: Max 10-25 mg/day (High risk of morning hangover and falls)." + }, + { + "label": "Best Uses", + "value": "Doxepin is a TCA used at low dose for insomnia and at high dose for depression, but has potent antihistaminic sedation and is dangerous in overdose." + }, + { + "label": "Avoid / Cautions", + "value": "Recent MI, heart block, severe BPH/urinary retention, concurrent MAOIs. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Profound next-day hangover, lethargy, delirium, cognitive blunting. Lowers seizure threshold. Gastrointestinal: Dry mouth, severe constipation. Cardiovascular: Fatal in overdose (arrhythmias). Orthostatic hypotension." + }, + { + "label": "Key Interactions", + "value": "Additive severe CNS depression with Opioids, Benzos, and Alcohol. **CYP2D6** inhibitors (Paroxetine) drastically spike Doxepin levels." + }, + { + "label": "Monitoring", + "value": "Baseline **ECG** before treating depression (High doses). Warn the patient not to drive the morning after their first dose due to the massive hangover effect." + }, + { + "label": "Clinical Pearl", + "value": "When a patient has end-stage renal failure or severe liver disease, they often develop a relentless, maddening whole-body itch (uremic/hepatic pruritus). Standard antihistamines do nothing. A tiny 10mg dose of Doxepin at night often cures the itch entirely and lets them sleep." + } + ] + }, + { + "slug": "duloxetine", + "name": "Duloxetine", + "class": "Antidepressant", + "subclass": "Balanced SNRI", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "SNRI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "120 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12 h", + "cls": "", + "flag": "" + }, + { + "label": "Neuropathy", + "value": "INDICATED", + "cls": "good", + "flag": "" + }, + { + "label": "Hepatic", + "value": "AVOID IN CIRRHOSIS", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent, balanced SNRI. Uniquely blocks serotonin and noradrenaline equally across all doses (unlike Venlafaxine). Excellent for major depression coupled with chronic pain/neuropathy.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **120 mg/day** (Benefits usually plateau at 60 mg/day).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Heavily hepatically metabolised. High risk of drug-induced liver injury. Strictly avoid in patients with heavy alcohol use or cirrhosis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Duloxetine is an SNRI effective for depression, GAD, neuropathic pain, and fibromyalgia, but causes nausea initially and has a severe discontinuation syndrome similar to venlafaxine.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea (extremely common, 25% of patients), dry mouth, constipation.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "CRITICAL — Severe transaminitis, jaundice, hepatic failure.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "HIGH — Insomnia, somnolence, dizziness. Discontinuation syndrome (brain zaps).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Mild hypertension (less severe than Venlafaxine).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Depression / GAD", + "val": "Start **PO** 30 mg **OD**. Titrate to 60 mg **OD** after 1-2 weeks. Max 120 mg/day.", + "tags": [] + }, + { + "key": "Diabetic Neuropathy / Fibromyalgia", + "val": "**PO** 60 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Avoid entirely if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Cymbalta, Andepra", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Enteric-coated pellets in capsules (30 mg, 60 mg). Do NOT crush or open (drug is destroyed by stomach acid).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder, GAD, Diabetic Peripheral Neuropathy, Fibromyalgia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Stress urinary incontinence in women.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The gold-standard antidepressant for a patient presenting with both severe depression and chronic nerve pain.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Hepatic impairment, concurrent MAOI use, uncontrolled narrow-angle glaucoma.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Duloxetine pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs, Tramadol (Fatal Serotonin Syndrome).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Potent **CYP1A2** inhibitors (Ciprofloxacin, Fluvoxamine) massively spike Duloxetine levels causing severe toxicity. Moderate inhibitor of CYP2D6.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and routine **LFTs**. Stop drug if enzymes rise. Check **U&E** (sodium) in the elderly for SIADH.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "Monitor **BP** periodically.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Nausea Fix", + "val": "Duloxetine causes fierce nausea because it spikes serotonin in the gut. Taking the capsule in the middle of a heavy meal dramatically blunts this. The nausea usually disappears after 7-10 days.", + "tags": [] + }, + { + "key": "The Balance Difference", + "val": "Venlafaxine only acts as an SNRI at doses > 150mg. Duloxetine acts as an SNRI starting at 30mg. If you need noradrenaline for nerve pain *now*, Duloxetine is much faster to titrate.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Dual Serotonin and Noradrenaline reuptake inhibitor. Enhances descending inhibitory pain pathways in the spinal cord (via noradrenaline).", + "tags": [] + }, + { + "key": "Onset", + "val": "1-2 weeks for pain. 4-6 weeks for depression.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12 hours. Highly protein bound (96%). Dual metabolism by CYP1A2 and CYP2D6.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CYMBALTA Australian PI, ARTG 199254, and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Balanced SNRI — Potent, balanced SNRI." + }, + { + "label": "Route / Formulation", + "value": "Enteric-coated pellets in capsules (30 mg, 60 mg). Do NOT crush or open (drug is destroyed by stomach acid). (Cymbalta, Andepra)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 30 mg **OD**. Titrate to 60 mg **OD** after 1-2 weeks. Max 120 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Depression / GAD: Start **PO** 30 mg **OD**. Titrate to 60 mg **OD** after 1-2 weeks. Max 120 mg/day. Diabetic Neuropathy / Fibromyalgia: **PO** 60 mg **OD**. Renal Impairment: Avoid entirely if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Duloxetine is an SNRI effective for depression, GAD, neuropathic pain, and fibromyalgia, but causes nausea initially and has a severe discontinuation syndrome similar to venlafaxine." + }, + { + "label": "Avoid / Cautions", + "value": "Hepatic impairment, concurrent MAOI use, uncontrolled narrow-angle glaucoma. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea (extremely common, 25% of patients), dry mouth, constipation. Hepatic: Severe transaminitis, jaundice, hepatic failure. Neurological: Insomnia, somnolence, dizziness. Discontinuation syndrome (brain zaps). Cardiovascular: Mild hypertension (less severe than Venlafaxine)." + }, + { + "label": "Key Interactions", + "value": "MAOIs, Tramadol (Fatal Serotonin Syndrome). Potent **CYP1A2** inhibitors (Ciprofloxacin, Fluvoxamine) massively spike Duloxetine levels causing severe toxicity. Moderate inhibitor of CYP2D6." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **LFTs**. Stop drug if enzymes rise. Check **U&E** (sodium) in the elderly for SIADH. Monitor **BP** periodically." + }, + { + "label": "Clinical Pearl", + "value": "Duloxetine causes fierce nausea because it spikes serotonin in the gut. Taking the capsule in the middle of a heavy meal dramatically blunts this. The nausea usually disappears after 7-10 days." + } + ] + }, + { + "slug": "escitalopram", + "name": "Escitalopram", + "class": "Antidepressant", + "subclass": "SSRI", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "SSRI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "30 h", + "cls": "", + "flag": "" + }, + { + "label": "QTc Risk", + "value": "DOSE-DEP", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Elderly Max", + "value": "10 mg/day", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The S-enantiomer of citalopram. The most highly selective SSRI available. Exceptional tolerability and efficacy, but carries a strict, dose-dependent risk of QTc prolongation.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day** (Adults) • Max **10 mg/day** (Elderly >65 yrs).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Do not exceed 10mg in the elderly due to severe QTc and hyponatremia risks.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Escitalopram is the most selective SSRI with strong efficacy for depression and generalised anxiety disorder, but prolongs QTc dose-dependently (max 20 mg/day) and has the same SSRI class risks.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Dose-dependent **QTc** prolongation. Can lead to fatal Torsades de Pointes if combined with other agents or in hypokalemia.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Metabolic", + "val": "HIGH — Hyponatremia (SIADH) in the elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea (usually milder than Sertraline/Fluoxetine).", + "tags": [] + }, + { + "key": "Endocrine/GU", + "val": "HIGH — Sexual dysfunction.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Depression / Anxiety", + "val": "Start **PO** 10 mg **OD**. May increase to Max 20 mg/day after 2-4 weeks.", + "tags": [] + }, + { + "key": "Elderly / Hepatic Impairment", + "val": "MANDATORY — Max **PO** 10 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lexapro, Lexam", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg, 20 mg). Oral drops (10 mg/mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder, Generalized Anxiety Disorder, Social Anxiety, OCD.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Arguably the most 'tolerable' SSRI. Often chosen for patients highly sensitive to the side effects of other antidepressants.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL - Concurrent MAOI use, congenital long QT syndrome, baseline clinically significant QT prolongation, or unreviewed combination with other QT-prolonging medicines.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 500 + } + }, + "note": "Escitalopram source review supports avoiding clinically significant QT prolongation risk and QT-prolonging combinations." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Escitalopram pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Avoid mixing with other QTc prolonging drugs (e.g., Amiodarone, Haloperidol, Sotalol).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Omeprazole inhibits CYP2C19, significantly increasing Escitalopram levels and QTc risk. Max Escitalopram dose is 10mg if on Omeprazole.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — NSAIDs (Bleeding risk).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG** to check QTc before escalating to 20 mg, especially in females > 65 years.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Laboratory", + "val": "MANDATORY — Check **U&E** (sodium) at 2-4 weeks in the elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 10mg Ceiling", + "val": "For patients over 65, the liver cannot clear the drug fast enough. 10mg in an 80-year-old gives the same blood levels as 20mg in a 30-year-old. Pushing to 20mg in the elderly provides zero extra mood benefit but massively risks a fatal cardiac arrhythmia.", + "tags": [] + }, + { + "key": "The Clean Profile", + "val": "Escitalopram has almost zero effect on CYP450 enzymes. It will not mess with the blood levels of other medications, making it excellent for polypharmacy patients (provided QTc is watched).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Pure, highly selective inhibition of the serotonin transporter (SERT). Removes the R-enantiomer found in Citalopram, which previously hindered receptor binding.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-6 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "30 hours. Metabolised by CYP2C19 and CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - LEXAPRO Australian PI/CMI and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SSRI — The S-enantiomer of citalopram." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg, 20 mg). Oral drops (10 mg/mL). (Lexapro, Lexam)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 10 mg **OD**. May increase to Max 20 mg/day after 2-4 weeks." + }, + { + "label": "Key Indication Doses", + "value": "Depression / Anxiety: Start **PO** 10 mg **OD**. May increase to Max 20 mg/day after 2-4 weeks. Elderly / Hepatic Impairment: Max **PO** 10 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Escitalopram is the most selective SSRI with strong efficacy for depression and generalised anxiety disorder, but prolongs QTc dose-dependently (max 20 mg/day) and has the same SSRI class risks." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent MAOI use. Baseline **QTc** > 500 ms. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Dose-dependent **QTc** prolongation. Can lead to fatal Torsades de Pointes if combined with other agents or in hypokalemia. Metabolic: Hyponatremia (SIADH) in the elderly. Gastrointestinal: Nausea (usually milder than Sertraline/Fluoxetine). Endocrine/GU: Sexual dysfunction." + }, + { + "label": "Key Interactions", + "value": "Avoid mixing with other QTc prolonging drugs (e.g., Amiodarone, Haloperidol, Sotalol). Omeprazole inhibits CYP2C19, significantly increasing Escitalopram levels and QTc risk. Max Escitalopram dose is 10mg if on Omeprazole. NSAIDs (Bleeding risk)." + }, + { + "label": "Monitoring", + "value": "Baseline **ECG** to check QTc before escalating to 20 mg, especially in females > 65 years. Check **U&E** (sodium) at 2-4 weeks in the elderly." + }, + { + "label": "Clinical Pearl", + "value": "For patients over 65, the liver cannot clear the drug fast enough. 10mg in an 80-year-old gives the same blood levels as 20mg in a 30-year-old. Pushing to 20mg in the elderly provides zero extra mood benefit but massively risks a fatal cardiac arrhythmia." + } + ] + }, + { + "slug": "fluoxetine", + "name": "Fluoxetine", + "class": "Antidepressant", + "subclass": "SSRI", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "SSRI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "80 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4-6 DAYS", + "cls": "warn", + "flag": "warn" + }, + { + "label": "CYP Inhibitor", + "value": "POTENT", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Activation", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The original SSRI (Prozac). Highly activating and boasts a phenomenally long half-life. Excellent for non-compliant patients, but a nightmare for drug interactions.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **80 mg/day** (e.g., OCD/Bulimia). Normal depression max is 20-40 mg/day.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Completely shuts down CYP2D6. Active metabolites stay in the blood for 5 WEEKS after stopping. You cannot safely start a new drug immediately after ceasing Fluoxetine.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Fluoxetine is the longest-acting SSRI ideal when discontinuation syndrome is a concern, but has a very long washout period (5 weeks) before MAOI initiation and causes more activation/insomnia than other SSRIs.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Insomnia, severe initial anxiety/agitation, tremor. CRITICAL — Serotonin Syndrome.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, diarrhea, anorexia (weight loss is common initially).", + "tags": [] + }, + { + "key": "Endocrine/GU", + "val": "HIGH — Sexual dysfunction.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hyponatremia (SIADH).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Depression / Anxiety", + "val": "**PO** 20 mg **OD** (strictly in the morning to prevent insomnia). Max 80 mg/day.", + "tags": [] + }, + { + "key": "Bulimia Nervosa", + "val": "**PO** 60 mg **OD** (Requires high doses for impulse control).", + "tags": [] + }, + { + "key": "Washout Period", + "val": "MANDATORY — Must wait exactly 5 WEEKS after stopping Fluoxetine before starting an MAOI (Phenelzine) or severe fatal Serotonin Syndrome will occur.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Prozac, Lovan, Zactin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets (20 mg). Dispersible tablets (20 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder, OCD, Bulimia Nervosa, PMDD.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The first-line SSRI for children and adolescents (best evidence base). Excellent for adults with high fatigue/hypersomnia who need an 'activating' kick.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent MAOI use, Pimozide use.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Fluoxetine pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Potent irreversible inhibitor of **CYP2D6**. Will completely block Codeine/Tramadol from working. Will massively spike levels of Risperidone, Metoprolol, and TCAs into the toxic range.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — NSAIDs and Aspirin (Doubles risk of upper GI bleeds).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn the patient about intense anxiety/jitteriness in the first week. Take in the morning only.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **U&E** (sodium) at 2-4 weeks in the elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Non-Compliance Cure", + "val": "Because Norfluoxetine lasts for 16 days in the blood, if a patient forgets their pill for 3 days, their blood levels barely drop. They suffer ZERO withdrawal or 'brain zaps'. It is the best drug for chaotic, non-compliant patients.", + "tags": [] + }, + { + "key": "The Washout Trap", + "val": "If you switch a patient from Fluoxetine to Clomipramine, the Fluoxetine is still blocking CYP2D6 a month later. The Clomipramine levels will spike and cause a fatal seizure. Always account for the 5-week washout.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selective inhibition of serotonin reuptake (SERT). Unique among SSRIs for antagonizing 5-HT2C receptors, which releases noradrenaline and dopamine (causing the activating/energizing effect).", + "tags": [] + }, + { + "key": "Onset", + "val": "2-6 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Parent drug: 4-6 Days. Active metabolite (Norfluoxetine): 16 DAYS.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - PROZAC Australian PI/CMI and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SSRI — The original SSRI (Prozac)." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets (20 mg). Dispersible tablets (20 mg). (Prozac, Lovan, Zactin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 20 mg **OD** (strictly in the morning to prevent insomnia). Max 80 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Depression / Anxiety: **PO** 20 mg **OD** (strictly in the morning to prevent insomnia). Max 80 mg/day. Bulimia Nervosa: **PO** 60 mg **OD** (Requires high doses for impulse control). Washout Period: Must wait exactly 5 WEEKS after stopping Fluoxetine before starting an MAOI (Phenelzine) or severe fatal Serotonin Syndrome will occur." + }, + { + "label": "Best Uses", + "value": "Fluoxetine is the longest-acting SSRI ideal when discontinuation syndrome is a concern, but has a very long washout period (5 weeks) before MAOI initiation and causes more activation/insomnia than other SSRIs." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent MAOI use, Pimozide use. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Insomnia, severe initial anxiety/agitation, tremor. CRITICAL — Serotonin Syndrome. Gastrointestinal: Nausea, diarrhea, anorexia (weight loss is common initially). Endocrine/GU: Sexual dysfunction. Metabolic: Hyponatremia (SIADH)." + }, + { + "label": "Key Interactions", + "value": "Potent irreversible inhibitor of **CYP2D6**. Will completely block Codeine/Tramadol from working. Will massively spike levels of Risperidone, Metoprolol, and TCAs into the toxic range. NSAIDs and Aspirin (Doubles risk of upper GI bleeds)." + }, + { + "label": "Monitoring", + "value": "Warn the patient about intense anxiety/jitteriness in the first week. Take in the morning only. Check **U&E** (sodium) at 2-4 weeks in the elderly." + }, + { + "label": "Clinical Pearl", + "value": "Because Norfluoxetine lasts for 16 days in the blood, if a patient forgets their pill for 3 days, their blood levels barely drop. They suffer ZERO withdrawal or 'brain zaps'. It is the best drug for chaotic, non-compliant patients." + } + ] + }, + { + "slug": "fluvoxamine", + "name": "Fluvoxamine", + "class": "Antidepressant", + "subclass": "SSRI (Sigma-1)", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "SSRI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "15 h", + "cls": "", + "flag": "" + }, + { + "label": "CYP Inhibitor", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "OCD", + "value": "GOLD STANDARD", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Unique SSRI with potent Sigma-1 receptor agonism. The gold standard for severe Obsessive-Compulsive Disorder (OCD). However, it is an incredibly dangerous inhibitor of liver enzymes.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg/day** (given in divided doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Completely shuts down CYP1A2. Fatal interaction with Clozapine, Agomelatine, and Theophylline.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Fluvoxamine is an SSRI primarily used for OCD with potent CYP1A2 inhibition, but has significant drug interactions (especially with clozapine and theophylline) and more GI side effects than other SSRIs.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea and vomiting (Higher rate than most other SSRIs, usually transient).", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Sedation (Unlike Fluoxetine which is activating, Fluvoxamine is mildly sedating, hence NOCTE dosing).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hyponatremia (SIADH).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Obsessive-Compulsive Disorder", + "val": "Start **PO** 50 mg **NOCTE**. Titrate up to 100-300 mg/day. Doses > 150 mg should be divided **BD**.", + "tags": [] + }, + { + "key": "Depression", + "val": "Start **PO** 50 mg **NOCTE**. Target 100-200 mg/day.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Luvox, Faverin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (50 mg, 100 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for OCD/Depression.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Obsessive-Compulsive Disorder, Major Depressive Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Niche use for severe OCD. Largely avoided for simple depression due to terrifying drug interaction profile.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL - Concurrent use of MAOIs, tizanidine, agomelatine, or other contraindicated serotonergic/interacting medicines. Avoid concurrent clozapine unless under specialist monitoring.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Fluvoxamine pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Absolute blockade of **CYP1A2** and **CYP2C19**. If given to a patient on Clozapine, Clozapine levels will skyrocket by 500-1000%, causing fatal seizures and coma. If given to a patient on Duloxetine or Agomelatine, severe liver toxicity ensues.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Run a comprehensive drug-interaction check before prescribing this drug.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **U&E** (sodium).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The OCD Specialist", + "val": "While Sertraline and Fluoxetine treat OCD, Fluvoxamine is universally regarded by psychiatrists as the most potent agent for crippling, treatment-resistant OCD due to the unique Sigma-1 action.", + "tags": [] + }, + { + "key": "The Clozapine Hack", + "val": "In highly specialized settings, psychiatrists actually *use* the deadly interaction on purpose. If a patient is rapid-metabolizer of Clozapine, giving them a tiny 25mg dose of Fluvoxamine safely boosts their Clozapine levels without needing to prescribe massive, toxic doses of Clozapine.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits serotonin reuptake. Unique potent agonism at the Sigma-1 receptor (which regulates glutamate/calcium signaling and neuroplasticity), thought to drive its superior efficacy in OCD.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-6 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "15 hours. Requires BD dosing at high levels.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - LUVOX Australian CMI and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SSRI (Sigma-1) — Unique SSRI with potent Sigma-1 receptor agonism." + }, + { + "label": "Route / Formulation", + "value": "Tablets (50 mg, 100 mg). (Luvox, Faverin)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 50 mg **NOCTE**. Titrate up to 100-300 mg/day. Doses > 150 mg should be divided **BD**. Max **300 mg/day** (given in divided doses)." + }, + { + "label": "Key Indication Doses", + "value": "Obsessive-Compulsive Disorder: Start **PO** 50 mg **NOCTE**. Titrate up to 100-300 mg/day. Doses > 150 mg should be divided **BD**. Depression: Start **PO** 50 mg **NOCTE**. Target 100-200 mg/day." + }, + { + "label": "Best Uses", + "value": "Fluvoxamine is an SSRI primarily used for OCD with potent CYP1A2 inhibition, but has significant drug interactions (especially with clozapine and theophylline) and more GI side effects than other SSRIs." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of MAOIs, Tizanidine, Agomelatine, or Tizanidine. Avoid concurrent Clozapine without specialist monitoring. **Pregnancy** Category B2." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea and vomiting (Higher rate than most other SSRIs, usually transient). Neurological: Sedation (Unlike Fluoxetine which is activating, Fluvoxamine is mildly sedating, hence NOCTE dosing). Metabolic: Hyponatremia (SIADH)." + }, + { + "label": "Key Interactions", + "value": "Absolute blockade of **CYP1A2** and **CYP2C19**. If given to a patient on Clozapine, Clozapine levels will skyrocket by 500-1000%, causing fatal seizures and coma. If given to a patient on Duloxetine or Agomelatine, severe liver toxicity ensues." + }, + { + "label": "Monitoring", + "value": "Run a comprehensive drug-interaction check before prescribing this drug. Routine **U&E** (sodium)." + }, + { + "label": "Clinical Pearl", + "value": "While Sertraline and Fluoxetine treat OCD, Fluvoxamine is universally regarded by psychiatrists as the most potent agent for crippling, treatment-resistant OCD due to the unique Sigma-1 action." + } + ] + }, + { + "slug": "imipramine", + "name": "Imipramine", + "class": "Antidepressant", + "subclass": "TCA", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "TCA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "200 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10-20 h", + "cls": "", + "flag": "" + }, + { + "label": "Enuresis", + "value": "PAEDS USE", + "cls": "good", + "flag": "" + }, + { + "label": "Toxicity in OD", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The very first Tricyclic Antidepressant (TCA). A highly potent serotonin and noradrenaline reuptake inhibitor. Extremely toxic in overdose. Uniquely used in pediatrics for bedwetting.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **200 mg/day** (Depression). Max **75 mg/day** (Childhood enuresis).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "As with all TCAs, a 10-day supply taken at once is a fatal cardiac overdose. Do not dispense large quantities to suicidal patients.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Imipramine is a classic TCA for depression and nocturnal enuresis in children, but is cardiotoxic in overdose and has significant anticholinergic and sedative effects.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — QRS widening, arrhythmias, heart block, severe orthostatic hypotension.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe dry mouth, constipation, urinary retention (desired in enuresis, dangerous in adults).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Sedation, delirium in the elderly, lowers seizure threshold.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Depression", + "val": "Start **PO** 25-50 mg **NOCTE**. Titrate up to 100-200 mg/day.", + "tags": [] + }, + { + "key": "Nocturnal Enuresis (Children > 6 yrs)", + "val": "**PO** 10-75 mg **NOCTE** (Strictly weight/age based. Used only after bed alarms/desmopressin fail).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Tofranil", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10, 25 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder, Nocturnal enuresis (bedwetting).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Largely obsolete for depression due to SSRIs. Retains a niche in treatment-resistant childhood bedwetting due to its profound anticholinergic bladder-relaxing effect.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Recent myocardial infarction, heart block, concurrent MAOIs, narrow-angle glaucoma.", + "tags": [] + }, + { + "key": "Elderly", + "val": "CRITICAL — Do not use. Will cause severe falls and confusion.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs, Tramadol (Serotonin Syndrome).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (Fluoxetine) spike Imipramine levels into the toxic range.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG** before escalating doses.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Keep medication locked away from children. A toddler ingesting a few adult tablets will suffer a fatal cardiac arrest.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Bedwetting Mechanism", + "val": "Imipramine stops bedwetting through three pathways: it paralyzes the bladder (anticholinergic), it makes sleep lighter so the child wakes to a full bladder (noradrenaline), and it alters ADH secretion.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits reuptake of serotonin and noradrenaline. Its strong muscarinic (M1) blockade paralyzes the detrusor muscle of the bladder and tightens the internal sphincter, stopping bedwetting.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-4 WEEKS for depression. Days for enuresis.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10-20 hours. Metabolised to the active drug desipramine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TOFRANIL Australian PI/CMI, ARTG 11064/60673, and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "TCA — The very first Tricyclic Antidepressant (TCA)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10, 25 mg). (Tofranil)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 25-50 mg **NOCTE**. Titrate up to 100-200 mg/day. Max **200 mg/day** (Depression)." + }, + { + "label": "Key Indication Doses", + "value": "Depression: Start **PO** 25-50 mg **NOCTE**. Titrate up to 100-200 mg/day. Nocturnal Enuresis (Children > 6 yrs): **PO** 10-75 mg **NOCTE** (Strictly weight/age based. Used only after bed alarms/desmopressin fail)." + }, + { + "label": "Best Uses", + "value": "Imipramine is a classic TCA for depression and nocturnal enuresis in children, but is cardiotoxic in overdose and has significant anticholinergic and sedative effects." + }, + { + "label": "Avoid / Cautions", + "value": "Recent myocardial infarction, heart block, concurrent MAOIs, narrow-angle glaucoma." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: QRS widening, arrhythmias, heart block, severe orthostatic hypotension. Gastrointestinal: Severe dry mouth, constipation, urinary retention (desired in enuresis, dangerous in adults). Neurological: Sedation, delirium in the elderly, lowers seizure threshold." + }, + { + "label": "Key Interactions", + "value": "MAOIs, Tramadol (Serotonin Syndrome). **CYP2D6** inhibitors (Fluoxetine) spike Imipramine levels into the toxic range." + }, + { + "label": "Monitoring", + "value": "Baseline **ECG** before escalating doses. Keep medication locked away from children. A toddler ingesting a few adult tablets will suffer a fatal cardiac arrest." + }, + { + "label": "Clinical Pearl", + "value": "Imipramine stops bedwetting through three pathways: it paralyzes the bladder (anticholinergic), it makes sleep lighter so the child wakes to a full bladder (noradrenaline), and it alters ADH secretion." + } + ] + }, + { + "slug": "mirtazapine", + "name": "Mirtazapine", + "class": "Antidepressant", + "subclass": "NaSSA", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "NaSSA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "45 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "20–40 h", + "cls": "", + "flag": "" + }, + { + "label": "Sedation", + "value": "HIGH @ LOW DOSE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Weight Gain", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Noradrenergic and Specific Serotonergic Antidepressant (NaSSA). Unique dual-action drug. Highly sedating and strongly stimulates appetite. Zero sexual side effects.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **45 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Displays an inverse dose-sedation relationship. 15mg puts you to sleep. 45mg keeps you awake.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Mirtazapine is a sedating antidepressant ideal for depression with insomnia and poor appetite, but causes significant weight gain and sedation that may limit long-term tolerability.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "HIGH — Massive appetite stimulation, severe weight gain (can be 10+ kg in a few months).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Profound sedation, hangover effect, dizziness.", + "tags": [] + }, + { + "key": "Haematological", + "val": "RARE — Agranulocytosis or neutropenia (must check FBC if patient develops sudden fever/sore throat).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Depression / Insomnia", + "val": "Start **PO** 15 mg **NOCTE**. Titrate to 30 mg or 45 mg for antidepressant effect.", + "tags": [] + }, + { + "key": "Frail / Underweight Elderly", + "val": "Start **PO** 15 mg **NOCTE**. (Used strategically to promote weight gain and sleep).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Avanza, Remeron, Mirtazapine ODT", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (15, 30, 45 mg). ODT Wafers (dissolve on tongue).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Severe insomnia, appetite stimulation in cancer/anorexia, prevention of nausea.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The gold-standard antidepressant for an elderly patient who is depressed, not eating, losing weight, and not sleeping. Kills three birds with one stone.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent use of MAOIs.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION - Pregnancy category B3. Use in pregnancy or lactation only after benefit-risk review; do not conflate pregnancy advice with the separate low sexual-dysfunction profile.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Mirtazapine pregnancy/lactation is a benefit-risk caution; source review does not support treating the current pregnancy row as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive sedation with alcohol, benzos, and opioids.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "MODERATE — Less risk of Serotonin Syndrome than SSRIs, but still a risk if combined with Tramadol or MAOIs.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and routine **Weight**, **BSL**, and **Lipids**. Ensure weight gain is not pushing patient into metabolic syndrome.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Ask about sore throat (agranulocytosis risk).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Inverse Sedation Paradox", + "val": "At 15mg, Mirtazapine's antihistamine (sedating) effect dominates. At 30mg and 45mg, the massive noradrenaline release overrides the histamine blockade, making the drug *activating*. If a patient on 15mg is too sedated during the day, paradoxically increasing the dose to 30mg will wake them up.", + "tags": [] + }, + { + "key": "The Antiemetic Hack", + "val": "Because it blocks 5-HT3 (exactly like Ondansetron), Mirtazapine is an incredibly potent anti-nausea drug, often used in oncology or hyperemesis.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Antagonises central alpha-2 presynaptic receptors, causing a massive release of noradrenaline and serotonin. Also potently blocks 5-HT2, 5-HT3 (antiemetic effect), and H1 histamine receptors (intense sedation/weight gain).", + "tags": [] + }, + { + "key": "Onset", + "val": "Sedation/Appetite is immediate. Antidepressant effect 2-4 weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "20-40 hours (Allows true once-daily dosing).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - AXIT Australian PI/CMI and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "NaSSA — Noradrenergic and Specific Serotonergic Antidepressant (NaSSA)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (15, 30, 45 mg). ODT Wafers (dissolve on tongue). (Avanza, Remeron, Mirtazapine ODT)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 15 mg **NOCTE**. Titrate to 30 mg or 45 mg for antidepressant effect. Max **45 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Depression / Insomnia: Start **PO** 15 mg **NOCTE**. Titrate to 30 mg or 45 mg for antidepressant effect. Frail / Underweight Elderly: Start **PO** 15 mg **NOCTE**. (Used strategically to promote weight gain and sleep)." + }, + { + "label": "Best Uses", + "value": "Mirtazapine is a sedating antidepressant ideal for depression with insomnia and poor appetite, but causes significant weight gain and sedation that may limit long-term tolerability." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of MAOIs. **Pregnancy** Category B3. Very safe regarding sexual dysfunction (does not cause it)." + }, + { + "label": "Key Risks", + "value": "Metabolic: Massive appetite stimulation, severe weight gain (can be 10+ kg in a few months). Neurological: Profound sedation, hangover effect, dizziness. Haematological: RARE — Agranulocytosis or neutropenia (must check FBC if patient develops sudden fever/sore throat)." + }, + { + "label": "Key Interactions", + "value": "Additive sedation with alcohol, benzos, and opioids. Less risk of Serotonin Syndrome than SSRIs, but still a risk if combined with Tramadol or MAOIs." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **Weight**, **BSL**, and **Lipids**. Ensure weight gain is not pushing patient into metabolic syndrome. Ask about sore throat (agranulocytosis risk)." + }, + { + "label": "Clinical Pearl", + "value": "At 15mg, Mirtazapine's antihistamine (sedating) effect dominates. At 30mg and 45mg, the massive noradrenaline release overrides the histamine blockade, making the drug *activating*. If a patient on 15mg is too sedated during the day, paradoxically increasing the dose to 30mg will wake them up." + } + ] + }, + { + "slug": "moclobemide", + "name": "Moclobemide", + "class": "Antidepressant", + "subclass": "RIMA", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "RIMA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "600 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1-2 h", + "cls": "", + "flag": "" + }, + { + "label": "Diet Restrictions", + "value": "MINIMAL", + "cls": "good", + "flag": "" + }, + { + "label": "Interactions", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Reversible Inhibitor of Monoamine Oxidase A (RIMA). Provides the unique efficacy of an MAOI without the terrifying, strict dietary restrictions (cheese effect).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **600 mg/day** (e.g., 300 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "While food interactions are rare, the drug interactions are STILL FATAL. Mixing Moclobemide with an SSRI will cause fatal Serotonin Syndrome.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Moclobemide is a reversible MAOI (RIMA) for depression with fewer dietary restrictions than irreversible MAOIs, but still carries serotonin syndrome risk and requires a washout period from other antidepressants.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Insomnia, dizziness, agitation, headache. CRITICAL — Serotonin Syndrome (if mixed with serotonergics).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea, dry mouth.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "SAFE — Weight neutral. Zero sexual dysfunction.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Major Depressive Disorder", + "val": "Start **PO** 150 mg **BD** (after meals). Titrate to 300-600 mg/day in divided doses.", + "tags": [] + }, + { + "key": "Social Anxiety", + "val": "**PO** 300 mg **BD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Aurorix, Amira", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (150 mg, 300 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder, Social Phobia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "A highly underutilized, excellent drug for social anxiety and atypical depression. Safer than irreversible MAOIs (Phenelzine).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent use of SSRIs, SNRIs, TCAs, Pethidine, or Tramadol.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Moclobemide pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — ANY serotonergic drug (SSRIs, MDMA, Dextromethorphan cough syrup). Will cause hyperthermia, seizures, and death.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Cimetidine (doubles moclobemide levels).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Must be taken strictly AFTER MEALS. This slows absorption and minimizes the peak concentration in the gut, reducing the tiny remaining risk of a tyramine (cheese) reaction.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Diet Truth", + "val": "Patients do NOT need a strict MAOI diet on Moclobemide. They can eat cheese and drink wine normally. The only exception is if they consume a *massive* amount of mature cheese (e.g., 200g of pure aged cheddar in one sitting), which could overwhelm the reversible blockade and cause a mild BP spike.", + "tags": [] + }, + { + "key": "The Short Washout", + "val": "Because it is reversible, the MAO enzyme is fully functional within 24 hours of stopping the drug. You only need to wait 2 days after stopping Moclobemide to safely start an SSRI (unlike the 14-day wait for Phenelzine).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Reversibly inhibits MAO-A, slowing the breakdown of Serotonin and Noradrenaline. Because it is *reversible*, if the patient eats a massive amount of Tyramine (cheese), the Tyramine will successfully push the Moclobemide off the enzyme, allowing the body to break the Tyramine down safely and preventing a stroke.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-4 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-2 hours. (Must be dosed BD).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - AURORIX Australian PI/CMI, ARTG 9987/51626, and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "RIMA — Reversible Inhibitor of Monoamine Oxidase A (RIMA)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (150 mg, 300 mg). (Aurorix, Amira)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 150 mg **BD** (after meals). Titrate to 300-600 mg/day in divided doses. Max **600 mg/day** (e.g., 300 mg BD)." + }, + { + "label": "Key Indication Doses", + "value": "Major Depressive Disorder: Start **PO** 150 mg **BD** (after meals). Titrate to 300-600 mg/day in divided doses. Social Anxiety: **PO** 300 mg **BD**." + }, + { + "label": "Best Uses", + "value": "Moclobemide is a reversible MAOI (RIMA) for depression with fewer dietary restrictions than irreversible MAOIs, but still carries serotonin syndrome risk and requires a washout period from other antidepressants." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of SSRIs, SNRIs, TCAs, Pethidine, or Tramadol. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Neurological: Insomnia, dizziness, agitation, headache. CRITICAL — Serotonin Syndrome (if mixed with serotonergics). Gastrointestinal: Nausea, dry mouth. Metabolic: Weight neutral. Zero sexual dysfunction." + }, + { + "label": "Key Interactions", + "value": "ANY serotonergic drug (SSRIs, MDMA, Dextromethorphan cough syrup). Will cause hyperthermia, seizures, and death. Cimetidine (doubles moclobemide levels)." + }, + { + "label": "Monitoring", + "value": "Must be taken strictly AFTER MEALS. This slows absorption and minimizes the peak concentration in the gut, reducing the tiny remaining risk of a tyramine (cheese) reaction. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Patients do NOT need a strict MAOI diet on Moclobemide. They can eat cheese and drink wine normally. The only exception is if they consume a *massive* amount of mature cheese (e.g., 200g of pure aged cheddar in one sitting), which could overwhelm the reversible blockade and cause a mild BP spike." + } + ] + }, + { + "slug": "nortriptyline", + "name": "Nortriptyline", + "class": "Antidepressant", + "subclass": "TCA", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "TCA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "150 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "30 h", + "cls": "", + "flag": "" + }, + { + "label": "Anticholinergic", + "value": "MODERATE", + "cls": "good", + "flag": "" + }, + { + "label": "Elderly", + "value": "SAFER TCA", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Secondary amine TCA (the active metabolite of Amitriptyline). Acts much more specifically on Noradrenaline. Significantly less sedating and less anticholinergic than Amitriptyline.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **150 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The preferred TCA for the elderly or those who cannot tolerate the severe morning grogginess and dry mouth of Amitriptyline.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Nortriptyline is a TCA with less sedation and anticholinergic effects than amitriptyline for neuropathic pain, but carries the same cardiac toxicity in overdose and requires ECG monitoring in elderly.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Still fatal in overdose (QRS widening, arrhythmias). **QTc** prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Dry mouth, constipation (half as severe as Amitriptyline).", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Insomnia/activating (due to strong noradrenaline effect), dizziness.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Neuropathic Pain / Migraine", + "val": "Start **PO** 10-25 mg **NOCTE**. Titrate up slowly to 50-75 mg/day.", + "tags": [] + }, + { + "key": "Depression", + "val": "Start **PO** 25-50 mg/day. Max 150 mg/day.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Start at 10 mg. (Much safer than Amitriptyline, but still requires caution).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Allegron", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg, 25 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Neuropathic pain, smoking cessation adjunct, migraine prophylaxis.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "First-line TCA choice for neuropathic pain when the patient needs to remain alert and functional during the day.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Recent myocardial infarction, concurrent MAOIs, heart block.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Nortriptyline pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs, Tramadol (Serotonin Syndrome).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (Fluoxetine, Bupropion) will spike Nortriptyline levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline **ECG** before escalating doses.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **TDM** (Nortriptyline levels) is available and highly accurate for ensuring therapeutic compliance in treatment-resistant depression.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Activation Shift", + "val": "Because Nortriptyline is heavy on Noradrenaline, some patients find it slightly stimulating rather than sedating. If it keeps them awake, switch the dose from NOCTE to the morning.", + "tags": [] + }, + { + "key": "The Therapeutic Window", + "val": "Nortriptyline exhibits a rare 'therapeutic window' for depression (blood levels 50-150 ng/mL). Doses too low don't work, but doses too high ALSO stop working. It must be dosed perfectly.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits reuptake of Noradrenaline (heavily) and Serotonin (weakly). Has significantly lower affinity for H1, M1, and Alpha-1 receptors compared to Amitriptyline, resulting in less sedation, less dry mouth, and less hypotension.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-4 weeks for pain/mood.", + "tags": [] + }, + { + "key": "Half-life", + "val": "15-39 hours (Metabolised by CYP2D6).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ALLEGRON Australian Medicine Finder PI/CMI and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "TCA — Secondary amine TCA (the active metabolite of Amitriptyline)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg, 25 mg). (Allegron)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 10-25 mg **NOCTE**. Titrate up slowly to 50-75 mg/day. Max **150 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Neuropathic Pain / Migraine: Start **PO** 10-25 mg **NOCTE**. Titrate up slowly to 50-75 mg/day. Depression: Start **PO** 25-50 mg/day. Max 150 mg/day. Elderly / Frail: Start at 10 mg. (Much safer than Amitriptyline, but still requires caution)." + }, + { + "label": "Best Uses", + "value": "Nortriptyline is a TCA with less sedation and anticholinergic effects than amitriptyline for neuropathic pain, but carries the same cardiac toxicity in overdose and requires ECG monitoring in elderly." + }, + { + "label": "Avoid / Cautions", + "value": "Recent myocardial infarction, concurrent MAOIs, heart block. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Still fatal in overdose (QRS widening, arrhythmias). **QTc** prolongation. Gastrointestinal: Dry mouth, constipation (half as severe as Amitriptyline). Neurological: Insomnia/activating (due to strong noradrenaline effect), dizziness." + }, + { + "label": "Key Interactions", + "value": "MAOIs, Tramadol (Serotonin Syndrome). **CYP2D6** inhibitors (Fluoxetine, Bupropion) will spike Nortriptyline levels." + }, + { + "label": "Monitoring", + "value": "Baseline **ECG** before escalating doses. Routine **TDM** (Nortriptyline levels) is available and highly accurate for ensuring therapeutic compliance in treatment-resistant depression." + }, + { + "label": "Clinical Pearl", + "value": "Because Nortriptyline is heavy on Noradrenaline, some patients find it slightly stimulating rather than sedating. If it keeps them awake, switch the dose from NOCTE to the morning." + } + ] + }, + { + "slug": "paroxetine", + "name": "Paroxetine", + "class": "Antidepressant", + "subclass": "SSRI", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "SSRI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "60 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "21 h", + "cls": "", + "flag": "" + }, + { + "label": "Withdrawal", + "value": "SEVERE", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Weight Gain", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The most sedating, weight-gaining, and anticholinergic of all the SSRIs. Highly effective for severe anxiety, but plagued by a horrific withdrawal syndrome and terrible side effects.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **60 mg/day** (Max 50 mg for Panic Disorder).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Has the shortest half-life and no active metabolites. Missing a single pill causes severe 'brain zaps' and withdrawal.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Paroxetine is an SSRI effective for depression and anxiety disorders, but has the worst discontinuation syndrome of all SSRIs and significant anticholinergic effects.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Discontinuation syndrome ('brain zaps', severe vertigo, flu-like symptoms). HIGH — Sedation, fatigue.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Dry mouth, severe constipation (due to anticholinergic effect).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Significant weight gain (worst of all SSRIs).", + "tags": [] + }, + { + "key": "Endocrine/GU", + "val": "CRITICAL — Severe sexual dysfunction (highest rate among SSRIs).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Depression / Severe Anxiety", + "val": "Start **PO** 20 mg **OD** (morning). Titrate to Max 50-60 mg/day.", + "tags": [] + }, + { + "key": "Panic Disorder", + "val": "Start **PO** 10 mg **OD** (to avoid initial panic exacerbation). Max 50 mg/day.", + "tags": [] + }, + { + "key": "Elderly", + "val": "MANDATORY — Max 40 mg/day. High risk of anticholinergic confusion.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Aropax, Paxtine", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (20 mg). Controlled Release (12.5 mg, 25 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder, OCD, Panic Disorder, Social Anxiety, PTSD.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Largely relegated to 3rd-line SSRI therapy due to weight gain and withdrawal risks. Still used for very severe, refractory anxiety.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent MAOI use.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Uniquely teratogenic among SSRIs (causes atrial/ventricular septal heart defects in the fetus).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Paroxetine has higher pregnancy concern than many SSRIs and should trigger avoid/specialist review rather than routine caution." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Potent irreversible inhibitor of **CYP2D6**. Will completely block the liver from converting Codeine or Tramadol into their active pain-killing forms. Will massively spike levels of Risperidone and Metoprolol.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Counsel strictly on daily adherence. Advise a prolonged, glacial taper (over months) if stopping the drug.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **U&E** (sodium) and **Weight**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Pregnancy Trap", + "val": "If a young woman on Paroxetine wishes to become pregnant, you MUST cross-taper her to Sertraline or Escitalopram months in advance. Paroxetine is strictly contraindicated in pregnancy.", + "tags": [] + }, + { + "key": "The Tamoxifen Failure", + "val": "Breast cancer patients on Tamoxifen rely on CYP2D6 to convert Tamoxifen into its active cancer-killing form (endoxifen). Paroxetine shuts down CYP2D6. Giving Paroxetine for hot flushes will cause the breast cancer treatment to fail.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent inhibitor of SERT. Unique among SSRIs for having significant affinity for Muscarinic (M1) receptors (causing anticholinergic side effects) and Nitric Oxide Synthase (causing sexual dysfunction).", + "tags": [] + }, + { + "key": "Onset", + "val": "2-6 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "21 hours. Completely destroys its own metabolizing enzyme (CYP2D6), leading to non-linear kinetics (small dose bumps cause huge blood level spikes).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - Paroxetine Australian CMI/PI search and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SSRI — The most sedating, weight-gaining, and anticholinergic of all the SSRIs." + }, + { + "label": "Route / Formulation", + "value": "Tablets (20 mg). Controlled Release (12.5 mg, 25 mg). (Aropax, Paxtine)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 20 mg **OD** (morning). Titrate to Max 50-60 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Depression / Severe Anxiety: Start **PO** 20 mg **OD** (morning). Titrate to Max 50-60 mg/day. Panic Disorder: Start **PO** 10 mg **OD** (to avoid initial panic exacerbation). Max 50 mg/day. Elderly: Max 40 mg/day. High risk of anticholinergic confusion." + }, + { + "label": "Best Uses", + "value": "Paroxetine is an SSRI effective for depression and anxiety disorders, but has the worst discontinuation syndrome of all SSRIs and significant anticholinergic effects." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent MAOI use. **Pregnancy** Category D. Uniquely teratogenic among SSRIs (causes atrial/ventricular septal heart defects in the fetus)." + }, + { + "label": "Key Risks", + "value": "Neurological: Discontinuation syndrome ('brain zaps', severe vertigo, flu-like symptoms). HIGH — Sedation, fatigue. Gastrointestinal: Dry mouth, severe constipation (due to anticholinergic effect). Metabolic: Significant weight gain (worst of all SSRIs). Endocrine/GU: Severe sexual dysfunction (highest rate among SSRIs)." + }, + { + "label": "Key Interactions", + "value": "Potent irreversible inhibitor of **CYP2D6**. Will completely block the liver from converting Codeine or Tramadol into their active pain-killing forms. Will massively spike levels of Risperidone and Metoprolol." + }, + { + "label": "Monitoring", + "value": "Counsel strictly on daily adherence. Advise a prolonged, glacial taper (over months) if stopping the drug. Routine **U&E** (sodium) and **Weight**." + }, + { + "label": "Clinical Pearl", + "value": "If a young woman on Paroxetine wishes to become pregnant, you MUST cross-taper her to Sertraline or Escitalopram months in advance. Paroxetine is strictly contraindicated in pregnancy." + } + ] + }, + { + "slug": "phenelzine", + "name": "Phenelzine", + "class": "Antidepressant", + "subclass": "Irreversible MAOI", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "MAOI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "90 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "11 h", + "cls": "", + "flag": "" + }, + { + "label": "Diet Restrictions", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Hypertensive Crisis", + "value": "RISK", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Irreversible Monoamine Oxidase Inhibitor (MAOI). The most potent class of antidepressants in existence. Highly effective for severe, atypical, treatment-resistant depression.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **90 mg/day** (e.g., 30 mg TDS).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Permanently destroys the MAO enzyme in the gut and brain. Eating Tyramine-rich foods (cheese, wine) causes a fatal hypertensive crisis (stroke/death).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Phenelzine is an irreversible MAOI for treatment-resistant depression and social phobia, but requires strict dietary tyramine restriction and has potentially fatal interactions with serotonergic drugs.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Hypertensive Crisis (Tyramine reaction: sudden explosive headache, stiff neck, vomiting, stroke, death). HIGH — Paradoxical postural hypotension (very common baseline side effect).", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Fatal Serotonin Syndrome (if mixed with SSRIs). HIGH — Insomnia, daytime somnolence, B6 deficiency (neuropathy).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Massive weight gain, peripheral edema.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Treatment Resistant Depression", + "val": "Start **PO** 15 mg **BD** or **TDS**. Titrate up to 60-90 mg/day. Reduce to maintenance dose (15-30 mg/day) once remission is achieved.", + "tags": [] + }, + { + "key": "Washout Period", + "val": "MANDATORY — Must wait 14 days after stopping an SSRI (or 5 weeks after Fluoxetine) before starting Phenelzine.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nardil", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (15 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Initiated by Psychiatrists only.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe Treatment-Resistant Depression, Atypical Depression (hyperphagia, hypersomnia, leaden paralysis), severe Panic/Social anxiety.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Last line of defense in psychiatry when SSRIs, SNRIs, TCAs, and ECT have completely failed.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Non-compliance. If the patient cannot be trusted to follow the strict diet, do not prescribe this drug. Pheochromocytoma, heart failure, severe liver disease.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Existing absolute row names severe liver disease; severe hepatic impairment is the modeled patient-panel match." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category B3 (Avoid due to intense BP fluctuations).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Dietary", + "val": "CRITICAL — Aged cheeses (Cheddar, Brie), cured meats (salami), tap beer, red wine, Marmite/Vegemite, soy sauce. (These contain Tyramine. Without MAO in the gut to destroy it, Tyramine floods the blood, forcing massive noradrenaline release).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — SSRIs, TCAs, Tramadol, Dextromethorphan (Cough syrup), Pseudoephedrine (Cold meds), Adrenaline. ALL ARE FATAL.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Strict dietary counseling. Provide the patient with an 'MAOI Alert Card'. Monitor **BP** for both severe postural drops and hypertensive spikes.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **LFTs** (rare hepatotoxicity).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Antidote", + "val": "If a patient eats a block of aged cheese and presents to ED with a BP of 240/140 and a pounding headache, you must treat the hypertensive crisis with IV Phentolamine or GTN infusion. Do not use beta-blockers.", + "tags": [] + }, + { + "key": "The Anaesthesia Ban", + "val": "If a patient on an MAOI needs emergency surgery, the anesthetist MUST be notified. Standard indirect sympathomimetics (like metaraminol or ephedrine) will cause a fatal BP spike.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Irreversibly binds and destroys Monoamine Oxidase A and B enzymes. This completely halts the breakdown of Serotonin, Noradrenaline, and Dopamine in the brain, flooding the synapses. Also halts the breakdown of Tyramine in the gut.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-6 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "11 hours (But the biological effect lasts 14 DAYS, as the body must synthesize entirely new MAO enzymes from scratch).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - NARDIL phenelzine ARTG/PI/CMI, TGA historical discontinuation notice, Healthdirect, and PBS search checked 2026-05-12 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Irreversible MAOI — Irreversible Monoamine Oxidase Inhibitor (MAOI)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (15 mg). (Nardil)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 15 mg **BD** or **TDS**. Titrate up to 60-90 mg/day. Reduce to maintenance dose (15-30 mg/day) once remission is achieved. Max **90 mg/day** (e.g., 30 mg TDS)." + }, + { + "label": "Key Indication Doses", + "value": "Treatment Resistant Depression: Start **PO** 15 mg **BD** or **TDS**. Titrate up to 60-90 mg/day. Reduce to maintenance dose (15-30 mg/day) once remission is achieved. Washout Period: Must wait 14 days after stopping an SSRI (or 5 weeks after Fluoxetine) before starting Phenelzine." + }, + { + "label": "Best Uses", + "value": "Phenelzine is an irreversible MAOI for treatment-resistant depression and social phobia, but requires strict dietary tyramine restriction and has potentially fatal interactions with serotonergic drugs." + }, + { + "label": "Avoid / Cautions", + "value": "Non-compliance. If the patient cannot be trusted to follow the strict diet, do not prescribe this drug. Pheochromocytoma, heart failure, severe liver disease. **Pregnancy** Category B3 (Avoid due to intense BP fluctuations)." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Hypertensive Crisis (Tyramine reaction: sudden explosive headache, stiff neck, vomiting, stroke, death). HIGH — Paradoxical postural hypotension (very common baseline side effect). Neurological: Fatal Serotonin Syndrome (if mixed with SSRIs). HIGH — Insomnia, daytime somnolence, B6 deficiency (neuropathy). Metabolic: Massive weight gain, peripheral edema." + }, + { + "label": "Key Interactions", + "value": "Aged cheeses (Cheddar, Brie), cured meats (salami), tap beer, red wine, Marmite/Vegemite, soy sauce. (These contain Tyramine. Without MAO in the gut to destroy it, Tyramine floods the blood, forcing massive noradrenaline release). SSRIs, TCAs, Tramadol, Dextromethorphan (Cough syrup), Pseudoephedrine (Cold meds), Adrenaline. ALL ARE FATAL." + }, + { + "label": "Monitoring", + "value": "Strict dietary counseling. Provide the patient with an 'MAOI Alert Card'. Monitor **BP** for both severe postural drops and hypertensive spikes. Routine **LFTs** (rare hepatotoxicity)." + }, + { + "label": "Clinical Pearl", + "value": "If a patient eats a block of aged cheese and presents to ED with a BP of 240/140 and a pounding headache, you must treat the hypertensive crisis with IV Phentolamine or GTN infusion. Do not use beta-blockers." + } + ] + }, + { + "slug": "reboxetine", + "name": "Reboxetine", + "class": "Antidepressant", + "subclass": "NRI", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "NRI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "12 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "13 h", + "cls": "", + "flag": "" + }, + { + "label": "Activation", + "value": "HIGH", + "cls": "warn", + "flag": "" + }, + { + "label": "Sweating", + "value": "SEVERE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly selective Noradrenaline Reuptake Inhibitor (NRI). Has absolutely zero effect on serotonin. Acts as an activating, 'wake-up' antidepressant for patients with severe fatigue and psychomotor retardation.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **12 mg/day** (Usually 4 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The massive noradrenaline boost acts like synthetic adrenaline on the body. High risk of tachycardia, sweating, and urinary retention.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Reboxetine is a selective noradrenaline reuptake inhibitor for depression, but has questionable efficacy compared to SSRIs and causes urinary retention, insomnia, and dry mouth.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Genitourinary", + "val": "HIGH — Urinary retention/hesitancy (especially in men with BPH), testicular pain.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Insomnia (do not take at night), agitation, anxiety, intense hyperhidrosis (sweating).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Tachycardia, palpitations, mild hypertension.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "SAFE — Weight neutral, zero sexual dysfunction.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Major Depressive Disorder", + "val": "Start **PO** 4 mg **BD** (morning and midday). Max 12 mg/day.", + "tags": [] + }, + { + "key": "Elderly / Renal / Hepatic", + "val": "MANDATORY — Start at **PO** 2 mg **BD**. Max 4 mg/day in severe CKD/Cirrhosis.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Edronax", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (4 mg). Usually scored to halve.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "ADHD (as an alternative to Atomoxetine/Stimulants).", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Niche drug. Used as an adjunct to SSRIs to provide energy and focus, or as monotherapy for patients who cannot tolerate serotonergic side effects (sexual dysfunction, weight gain).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent MAOI use.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CAUTION — Uncontrolled hypertension, recent MI, severe BPH, glaucoma.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Reboxetine pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs (Fatal hypertensive crisis).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong **CYP3A4** inhibitors (Clarithromycin, Ketoconazole) spike Reboxetine levels, worsening tachycardia and urinary retention.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Check **BP** and **HR** at baseline and follow-up. Monitor bladder output in elderly males.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Sweating Trap", + "val": "Patients will frequently complain of profuse, drenching sweats on Reboxetine. This is a direct physiological result of excess noradrenaline on the sweat glands, not a fever or infection. Alpha-blockers (like Clonidine) can reduce this if the drug is otherwise working perfectly.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selectively inhibits the reuptake of Noradrenaline (NET), increasing noradrenergic tone in the prefrontal cortex. Zero affinity for muscarinic, histaminic, or alpha-1 receptors.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-4 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "13 hours. Metabolised by CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - EDRONAX Australian PI/CMI, ARTG 521130, and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "NRI — Highly selective Noradrenaline Reuptake Inhibitor (NRI)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (4 mg). Usually scored to halve. (Edronax)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 4 mg **BD** (morning and midday). Max 12 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Major Depressive Disorder: Start **PO** 4 mg **BD** (morning and midday). Max 12 mg/day. Elderly / Renal / Hepatic: Start at **PO** 2 mg **BD**. Max 4 mg/day in severe CKD/Cirrhosis." + }, + { + "label": "Best Uses", + "value": "Reboxetine is a selective noradrenaline reuptake inhibitor for depression, but has questionable efficacy compared to SSRIs and causes urinary retention, insomnia, and dry mouth." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent MAOI use. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Genitourinary: Urinary retention/hesitancy (especially in men with BPH), testicular pain. Neurological: Insomnia (do not take at night), agitation, anxiety, intense hyperhidrosis (sweating). Cardiovascular: Tachycardia, palpitations, mild hypertension. Metabolic: Weight neutral, zero sexual dysfunction." + }, + { + "label": "Key Interactions", + "value": "MAOIs (Fatal hypertensive crisis). Strong **CYP3A4** inhibitors (Clarithromycin, Ketoconazole) spike Reboxetine levels, worsening tachycardia and urinary retention." + }, + { + "label": "Monitoring", + "value": "Check **BP** and **HR** at baseline and follow-up. Monitor bladder output in elderly males. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Patients will frequently complain of profuse, drenching sweats on Reboxetine. This is a direct physiological result of excess noradrenaline on the sweat glands, not a fever or infection. Alpha-blockers (like Clonidine) can reduce this if the drug is otherwise working perfectly." + } + ] + }, + { + "slug": "sertraline", + "name": "Sertraline", + "class": "Antidepressant", + "subclass": "SSRI", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "SSRI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "200 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "26 h", + "cls": "", + "flag": "" + }, + { + "label": "GI Upset", + "value": "COMMON", + "cls": "warn", + "flag": "" + }, + { + "label": "Post-MI Safe", + "value": "YES", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Selective Serotonin Reuptake Inhibitor (SSRI). Highly effective, broadly tolerated. Unique among SSRIs for having the best cardiovascular safety profile.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **200 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Often causes intense nausea and diarrhea in the first 1-2 weeks. Must counsel patients to push through it.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Sertraline is the first-line SSRI for depression, anxiety, PTSD, and OCD with the best cardiovascular safety profile, but causes GI side effects initially and carries serotonin syndrome risk with other serotonergic drugs.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, diarrhea, dyspepsia (Serotonin receptors in the gut are heavily stimulated).", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Insomnia, tremor, activation/anxiety in the first 2 weeks. CRITICAL — Serotonin Syndrome.", + "tags": [] + }, + { + "key": "Endocrine/GU", + "val": "HIGH — Sexual dysfunction (anorgasmia, decreased libido).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hyponatremia (SIADH), especially in the elderly.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Depression / Anxiety / PTSD", + "val": "Start **PO** 50 mg **OD** (morning). Titrate by 50 mg increments every 2-4 weeks to target response. Max 200 mg/day.", + "tags": [] + }, + { + "key": "Panic Disorder / Frail Elderly", + "val": "Start **PO** 25 mg **OD** to minimize early activating anxiety/nausea.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zoloft, Eleva", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (50 mg, 100 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder (MDD), OCD, Panic Disorder, PTSD, Social Anxiety.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line SSRI for almost all indications. Absolute first choice for patients with ischemic heart disease or recent MI (SADHART trial).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent use of MAOIs (causes fatal Serotonin Syndrome).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION - Pregnancy category C. Often selected when an SSRI is needed in pregnancy or lactation, but still requires individual benefit-risk review and neonatal/perinatal counselling.", + "tags": [], + "patient": { + "factors": ["pregnancy", "lactation"], + "action": "caution", + "severity": "caution", + "note": "Sertraline is commonly used in perinatal practice, but the source-reviewed row should remain a caution rather than SAFE or an absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs, Tramadol, Tapentadol, St John's Wort. Massive risk of Serotonin Syndrome (hyperthermia, clonus, rigidity, death).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — NSAIDs and Aspirin. SSRIs deplete platelet serotonin, doubling the risk of upper GI bleeds. Cover with PPI if combined.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **U&E** (sodium) 2-4 weeks after initiation in elderly patients due to SIADH risk.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "MANDATORY — Monitor for increased suicidal ideation in the first 2-4 weeks (energy returns before mood improves in adolescents/young adults).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Jittery Start", + "val": "Patients often quit Sertraline on Day 3 because it makes them feel 'wired, sick, and anxious'. Warn them that the brain takes 2 weeks to downregulate serotonin receptors, and the anxiety WILL pass. Prescribe short-term diazepam if necessary.", + "tags": [] + }, + { + "key": "The Cardiac Champion", + "val": "Unlike Citalopram/Escitalopram (QTc risk) or TCAs (arrhythmias), Sertraline has zero cardiac toxicity. It is the only antidepressant proven entirely safe to start the day after a heart attack.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent and highly selective inhibitor of the serotonin transporter (SERT), increasing synaptic serotonin. Also has very mild dopamine reuptake inhibition (DRI) at high doses.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-6 WEEKS for full psychiatric response. GI side effects begin on Day 1.", + "tags": [] + }, + { + "key": "Half-life", + "val": "26 hours. Extensive hepatic metabolism.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ZOLOFT Australian PI/CMI and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SSRI — Selective Serotonin Reuptake Inhibitor (SSRI)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (50 mg, 100 mg). (Zoloft, Eleva)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 50 mg **OD** (morning). Titrate by 50 mg increments every 2-4 weeks to target response. Max 200 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Depression / Anxiety / PTSD: Start **PO** 50 mg **OD** (morning). Titrate by 50 mg increments every 2-4 weeks to target response. Max 200 mg/day. Panic Disorder / Frail Elderly: Start **PO** 25 mg **OD** to minimize early activating anxiety/nausea." + }, + { + "label": "Best Uses", + "value": "Sertraline is the first-line SSRI for depression, anxiety, PTSD, and OCD with the best cardiovascular safety profile, but causes GI side effects initially and carries serotonin syndrome risk with other serotonergic drugs." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of MAOIs (causes fatal Serotonin Syndrome). **Pregnancy** Category C. Considered one of the safest SSRIs for breastfeeding/pregnancy." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea, diarrhea, dyspepsia (Serotonin receptors in the gut are heavily stimulated). Neurological: Insomnia, tremor, activation/anxiety in the first 2 weeks. CRITICAL — Serotonin Syndrome. Endocrine/GU: Sexual dysfunction (anorgasmia, decreased libido). Metabolic: Hyponatremia (SIADH), especially in the elderly." + }, + { + "label": "Key Interactions", + "value": "MAOIs, Tramadol, Tapentadol, St John's Wort. Massive risk of Serotonin Syndrome (hyperthermia, clonus, rigidity, death). NSAIDs and Aspirin. SSRIs deplete platelet serotonin, doubling the risk of upper GI bleeds. Cover with PPI if combined." + }, + { + "label": "Monitoring", + "value": "Check **U&E** (sodium) 2-4 weeks after initiation in elderly patients due to SIADH risk. Monitor for increased suicidal ideation in the first 2-4 weeks (energy returns before mood improves in adolescents/young adults)." + }, + { + "label": "Clinical Pearl", + "value": "Patients often quit Sertraline on Day 3 because it makes them feel 'wired, sick, and anxious'. Warn them that the brain takes 2 weeks to downregulate serotonin receptors, and the anxiety WILL pass. Prescribe short-term diazepam if necessary." + } + ] + }, + { + "slug": "tranylcypromine", + "name": "Tranylcypromine", + "class": "Antidepressant", + "subclass": "Irreversible MAOI", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "MAOI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "60 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "Diet Restrictions", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Activation", + "value": "HIGH", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Irreversible Monoamine Oxidase Inhibitor (MAOI). Structurally related to amphetamine. Exceptionally potent, highly stimulating, and fast-acting, but carries the same lethal dietary and drug interactions as Phenelzine.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **30 mg/day** in the current Australian Parnate source; any higher specialist dosing should be explicitly source-checked before display.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly activating. Must be taken in the morning to prevent severe insomnia. Strict Tyramine-free diet is mandatory.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Tranylcypromine is an irreversible MAOI for treatment-resistant depression, but has the most stimulant-like profile and requires the same strict tyramine dietary restrictions as phenelzine.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Hypertensive Crisis (if tyramine is ingested or sympathomimetics are given). HIGH — Orthostatic hypotension (can be severe).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Insomnia, severe agitation, hypomania, tremor. CRITICAL — Serotonin Syndrome (with SSRIs).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "LOW — Unlike Phenelzine, Tranylcypromine causes very little weight gain and less sexual dysfunction.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Treatment Resistant Depression", + "val": "Start **PO** 10 mg morning and 10 mg afternoon. If no satisfactory response after two weeks, add 10 mg at midday; doses above 30 mg/day are not supported by the checked Australian source.", + "tags": [] + }, + { + "key": "Washout Period", + "val": "MANDATORY — Must wait 14 days after stopping an SSRI (or 5 weeks after Fluoxetine) before starting Tranylcypromine.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Parnate", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Initiated by Psychiatrists only.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Severe Treatment-Resistant Depression (especially melancholic, psychomotor-retarded depression).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Used when the patient needs the immense power of an MAOI but also requires the stimulating, 'amphetamine-like' kick to get out of bed.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Non-compliance with diet. Pheochromocytoma, cardiovascular disease, concurrent SSRIs/SNRIs.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Dietary", + "val": "CRITICAL — Aged cheeses, cured meats, tap beer, Vegemite/Marmite, fermented soy (Tyramine).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Cold and flu tablets containing Pseudoephedrine/Phenylephrine will cause a fatal stroke. SSRIs and Tramadol cause fatal Serotonin Syndrome.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Check **BP** sitting and standing. Orthostatic hypotension is the most common reason for ceasing the drug.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Provide an 'MAOI Alert Card'.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Afternoon Ban", + "val": "Never prescribe Tranylcypromine after 3 PM. Its amphetamine-like structure will guarantee the patient does not sleep for 24 hours.", + "tags": [] + }, + { + "key": "The Cheese Reaction", + "val": "The Tyramine diet is not a 'suggestion'. A single slice of aged cheddar cheese contains enough Tyramine to spike the patient's BP to 250/140, leading to a subarachnoid hemorrhage.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Irreversibly destroys MAO-A and MAO-B, preventing the breakdown of monoamines. Structurally similar to amphetamine, causing direct release of dopamine/noradrenaline.", + "tags": [] + }, + { + "key": "Onset", + "val": "1-3 WEEKS (Slightly faster onset than Phenelzine).", + "tags": [] + }, + { + "key": "Half-life", + "val": "2 hours (But MAO enzyme regeneration takes 14 DAYS).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - PARNATE Australian Medicine Finder PI/CMI, ARTG 174086, and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Irreversible MAOI — Irreversible Monoamine Oxidase Inhibitor (MAOI)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg). (Parnate)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 10 mg **BD** (morning and midday). Titrate to 30-60 mg/day. Max **60 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Treatment Resistant Depression: Start **PO** 10 mg **BD** (morning and midday). Titrate to 30-60 mg/day. Washout Period: Must wait 14 days after stopping an SSRI (or 5 weeks after Fluoxetine) before starting Tranylcypromine." + }, + { + "label": "Best Uses", + "value": "Tranylcypromine is an irreversible MAOI for treatment-resistant depression, but has the most stimulant-like profile and requires the same strict tyramine dietary restrictions as phenelzine." + }, + { + "label": "Avoid / Cautions", + "value": "Non-compliance with diet. Pheochromocytoma, cardiovascular disease, concurrent SSRIs/SNRIs. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Hypertensive Crisis (if tyramine is ingested or sympathomimetics are given). HIGH — Orthostatic hypotension (can be severe). Neurological: Insomnia, severe agitation, hypomania, tremor. CRITICAL — Serotonin Syndrome (with SSRIs). Metabolic: Unlike Phenelzine, Tranylcypromine causes very little weight gain and less sexual dysfunction." + }, + { + "label": "Key Interactions", + "value": "Aged cheeses, cured meats, tap beer, Vegemite/Marmite, fermented soy (Tyramine). Cold and flu tablets containing Pseudoephedrine/Phenylephrine will cause a fatal stroke. SSRIs and Tramadol cause fatal Serotonin Syndrome." + }, + { + "label": "Monitoring", + "value": "Check **BP** sitting and standing. Orthostatic hypotension is the most common reason for ceasing the drug. Provide an 'MAOI Alert Card'." + }, + { + "label": "Clinical Pearl", + "value": "Never prescribe Tranylcypromine after 3 PM. Its amphetamine-like structure will guarantee the patient does not sleep for 24 hours." + } + ] + }, + { + "slug": "venlafaxine-xr", + "name": "Venlafaxine XR", + "class": "Antidepressant", + "subclass": "SNRI", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "SNRI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "225 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5 h (Act: 11h)", + "cls": "", + "flag": "" + }, + { + "label": "Hypertension", + "value": "DOSE-DEP", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Withdrawal", + "value": "SEVERE", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Serotonin-Noradrenaline Reuptake Inhibitor (SNRI). Highly effective for severe/refractory depression. The noradrenaline blockade kicks in at higher doses, providing an activating, energy-boosting effect.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **225 mg/day** (Specialist psych regimens may occasionally push to 375 mg).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Missing even a single dose triggers a horrifying withdrawal syndrome ('brain zaps', severe vertigo, flu-like crash).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Venlafaxine XR is a potent SNRI for depression, GAD, and neuropathic pain, but causes dose-dependent hypertension requiring BP monitoring and has a severe discontinuation syndrome if stopped abruptly.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Discontinuation syndrome ('Brain zaps', dizziness, sensory disturbances, crying spells). HIGH — Insomnia, severe sweating, tremor.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Dose-dependent hypertension and tachycardia (due to noradrenaline excess).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea (severe upon initiation).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Depression / GAD / Panic", + "val": "Start **PO** 75 mg **OD** (XR capsule). Titrate by 75 mg increments every 2-4 weeks. Max 225 mg/day.", + "tags": [] + }, + { + "key": "Severe Anxiety / Frail", + "val": "Start **PO** 37.5 mg **OD** (XR capsule) for the first week to blunt intense initial anxiety/nausea.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Efexor-XR, Elaxine PR", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Extended Release Capsules (37.5 mg, 75 mg, 150 mg). Do not crush. Patient may see intact ghost capsule in stool.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder, GAD, Panic Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Second-line after SSRI failure, or first-line for severe melancholic, low-energy depression.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent MAOI use (Fatal Serotonin Syndrome), uncontrolled severe hypertension.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B2. Can cause severe withdrawal symptoms in the neonate if used until term.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Venlafaxine pregnancy row should trigger benefit-risk and neonatal adaptation counselling; it should not trigger a paediatric contraindication simply because neonatal symptoms are mentioned." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — MAOIs, Tramadol, St John's Wort. Extreme risk of Serotonin Syndrome.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — NSAIDs (Bleeding risk).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Baseline and routine **BP** and **HR** checks. If a patient develops hypertension > 150/90, reduce the dose or cease.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **U&E** (sodium) for SIADH risk.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Dose Threshold", + "val": "If you prescribe 75mg of Venlafaxine, you are effectively just prescribing a highly toxic, hard-to-stop SSRI. You MUST push the dose to 150mg or 225mg to actually unlock the noradrenaline (SNRI) benefits.", + "tags": [] + }, + { + "key": "The Brain Zaps", + "val": "Venlafaxine has one of the shortest half-lives in psychiatry. If a patient takes their pill at 8 AM, and forgets the next day, by 12 PM they will feel 'electric shocks' in their head and severe vertigo. Counsel heavily on strict adherence.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "At 75 mg, it acts almost exclusively as an SSRI. At 150-225 mg, it strongly inhibits Noradrenaline reuptake. At >225 mg, it begins to weakly inhibit Dopamine reuptake.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-6 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5 hours (Parent drug). Active metabolite (desvenlafaxine) has an 11-hour half-life. The XR capsule matrix dictates the 24-hour clinical duration.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - EFEXOR-XR Australian PI/CMI and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SNRI — Serotonin-Noradrenaline Reuptake Inhibitor (SNRI)." + }, + { + "label": "Route / Formulation", + "value": "Extended Release Capsules (37.5 mg, 75 mg, 150 mg). Do not crush. Patient may see intact ghost capsule in stool. (Efexor-XR, Elaxine PR)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 75 mg **OD** (XR capsule). Titrate by 75 mg increments every 2-4 weeks. Max 225 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Depression / GAD / Panic: Start **PO** 75 mg **OD** (XR capsule). Titrate by 75 mg increments every 2-4 weeks. Max 225 mg/day. Severe Anxiety / Frail: Start **PO** 37.5 mg **OD** (XR capsule) for the first week to blunt intense initial anxiety/nausea." + }, + { + "label": "Best Uses", + "value": "Venlafaxine XR is a potent SNRI for depression, GAD, and neuropathic pain, but causes dose-dependent hypertension requiring BP monitoring and has a severe discontinuation syndrome if stopped abruptly." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent MAOI use (Fatal Serotonin Syndrome), uncontrolled severe hypertension. **Pregnancy** Category B2. Can cause severe withdrawal symptoms in the neonate if used until term." + }, + { + "label": "Key Risks", + "value": "Neurological: Discontinuation syndrome ('Brain zaps', dizziness, sensory disturbances, crying spells). HIGH — Insomnia, severe sweating, tremor. Cardiovascular: Dose-dependent hypertension and tachycardia (due to noradrenaline excess). Gastrointestinal: Nausea (severe upon initiation)." + }, + { + "label": "Key Interactions", + "value": "MAOIs, Tramadol, St John's Wort. Extreme risk of Serotonin Syndrome. NSAIDs (Bleeding risk)." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **BP** and **HR** checks. If a patient develops hypertension > 150/90, reduce the dose or cease. Routine **U&E** (sodium) for SIADH risk." + }, + { + "label": "Clinical Pearl", + "value": "If you prescribe 75mg of Venlafaxine, you are effectively just prescribing a highly toxic, hard-to-stop SSRI. You MUST push the dose to 150mg or 225mg to actually unlock the noradrenaline (SNRI) benefits." + } + ] + }, + { + "slug": "vortioxetine", + "name": "Vortioxetine", + "class": "Antidepressant", + "subclass": "Multimodal (SERT + 5HT1A/3/7)", + "category": "Psychiatry - Antidepressants", + "accent": "#7c3aed", + "tag": "MULTIMODAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "66 h", + "cls": "", + "flag": "" + }, + { + "label": "Nausea", + "value": "COMMON", + "cls": "warn", + "flag": "" + }, + { + "label": "Cognition", + "value": "IMPROVES", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Modern 'Multimodal' antidepressant. Combines SSRI activity with direct modulation of multiple other serotonin receptors. Clinically proven to improve cognitive fog in depression.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Exceptionally high rates of nausea, but boasts zero weight gain and virtually zero sexual dysfunction.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Vortioxetine is a multimodal antidepressant with pro-cognitive effects and good tolerability, but is expensive and nausea is common at higher doses.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea (Affects up to 30% of patients, often transient but can be severe enough to cause cessation), vomiting, constipation.", + "tags": [] + }, + { + "key": "Neurological", + "val": "LOW — Dizziness, abnormal dreams.", + "tags": [] + }, + { + "key": "Endocrine", + "val": "SAFE — Incidence of sexual dysfunction is at placebo levels (a massive advantage over SSRIs).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Major Depressive Disorder", + "val": "Start **PO** 10 mg **OD**. May increase to 20 mg/day or reduce to 5 mg/day based on response/nausea.", + "tags": [] + }, + { + "key": "Elderly (> 65 yrs)", + "val": "MANDATORY — Start at 5 mg **OD**. Max 10 mg/day.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Brintellix", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg, 10 mg, 20 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Major Depressive Disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Excellent 2nd-line option for patients who suffer from severe sexual dysfunction on SSRIs, or those complaining of profound 'brain fog' and poor concentration from their depression.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent MAOI use.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Vortioxetine pregnancy row is a caution/benefit-risk prompt in this guide; it is not treated as an automatic absolute contraindication from the checked Australian source." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong **CYP2D6** inhibitors (Bupropion, Fluoxetine) double the blood levels of Vortioxetine. Halve the dose.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong CYP inducers (Rifampicin, Carbamazepine) wipe out the drug. Must double the dose.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "MODERATE — Additive risk of Serotonin Syndrome with Tramadol or St John's Wort.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Counsel the patient to take the tablet with a large meal to blunt the intense nausea.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Cognitive Edge", + "val": "In clinical trials, Vortioxetine significantly improved executive function, processing speed, and memory in depressed patients independently of its mood-lifting effects. Great for working professionals.", + "tags": [] + }, + { + "key": "The Long Tail", + "val": "Because of its massive 66-hour half-life, it naturally auto-tapers out of the body over 2 weeks if stopped abruptly. It causes almost zero 'brain zaps' or discontinuation syndrome compared to Paroxetine or Venlafaxine.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits the serotonin transporter (SERT). Also acts as an agonist at 5-HT1A, partial agonist at 5-HT1B, and antagonist at 5-HT3 and 5-HT7. This complex receptor interplay enhances downstream release of dopamine, noradrenaline, and acetylcholine in the prefrontal cortex.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-4 WEEKS.", + "tags": [] + }, + { + "key": "Half-life", + "val": "66 hours. Extensively metabolised by CYP2D6.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - BRINTELLIX Australian PI/CMI, ARTG 203970, and PBS search checked 2026-05-10 for antidepressant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Multimodal (SERT + 5HT1A/3/7) — Modern 'Multimodal' antidepressant." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg, 10 mg, 20 mg). (Brintellix)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 10 mg **OD**. May increase to 20 mg/day or reduce to 5 mg/day based on response/nausea. Max **20 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Major Depressive Disorder: Start **PO** 10 mg **OD**. May increase to 20 mg/day or reduce to 5 mg/day based on response/nausea. Elderly (> 65 yrs): Start at 5 mg **OD**. Max 10 mg/day." + }, + { + "label": "Best Uses", + "value": "Vortioxetine is a multimodal antidepressant with pro-cognitive effects and good tolerability, but is expensive and nausea is common at higher doses." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent MAOI use. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Nausea (Affects up to 30% of patients, often transient but can be severe enough to cause cessation), vomiting, constipation. Neurological: Dizziness, abnormal dreams. Endocrine: Incidence of sexual dysfunction is at placebo levels (a massive advantage over SSRIs)." + }, + { + "label": "Key Interactions", + "value": "Strong **CYP2D6** inhibitors (Bupropion, Fluoxetine) double the blood levels of Vortioxetine. Halve the dose. Strong CYP inducers (Rifampicin, Carbamazepine) wipe out the drug. Must double the dose. Additive risk of Serotonin Syndrome with Tramadol or St John's Wort." + }, + { + "label": "Monitoring", + "value": "Counsel the patient to take the tablet with a large meal to blunt the intense nausea. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "In clinical trials, Vortioxetine significantly improved executive function, processing speed, and memory in depressed patients independently of its mood-lifting effects. Great for working professionals." + } + ] + }, + { + "slug": "aripiprazole", + "name": "Aripiprazole", + "class": "Antipsychotic", + "subclass": "SGA / Partial Agonist", + "category": "Psychiatry - Antipsychotics", + "accent": "#059669", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "30 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "75 h", + "cls": "", + "flag": "" + }, + { + "label": "Akathisia", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Metabolic", + "value": "LOW RISK", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Unique 'third-generation' antipsychotic. Acts as a partial D2 agonist. Highly activating, weight-neutral, but notorious for causing severe akathisia.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **30 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Very long half-life (75 hours). Takes up to 2 weeks to reach steady state. Do not up-titrate too quickly.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Aripiprazole is a unique partial dopamine agonist antipsychotic with the lowest metabolic risk in its class, but can cause paradoxical akathisia and activation early in treatment.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Akathisia (intense, agonizing inner restlessness and inability to sit still). Often mistaken for worsening agitation. HIGH — Insomnia, activating effects.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "LOW — Highly weight-neutral, zero prolactin elevation (in fact, it lowers prolactin).", + "tags": [] + }, + { + "key": "Psychiatric", + "val": "MODERATE — Impulse control disorders (gambling, hypersexuality) due to partial D2 agonism in the reward pathways.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia", + "val": "**PO** 10-15 mg **OD** (morning). Max 30 mg/day.", + "tags": [] + }, + { + "key": "Bipolar Maintenance", + "val": "**PO** 15 mg **OD**.", + "tags": [] + }, + { + "key": "Adjunct for Depression", + "val": "**PO** 2-5 mg **OD** (Off-label).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "**PO** 5-10 mg **OD** (morning). Max **10 mg/day** in elderly. Lower starting dose preferred due to akathisia risk.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Abilify, Abilify Maintena (LAI)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (2 mg to 30 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia, Bipolar I disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Treatment-resistant major depressive disorder (adjunct).", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Preferred choice for young patients or those refusing meds due to weight gain. Best metabolic profile of the oral SGAs.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known severe hypersensitivity.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Aripiprazole pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (Fluoxetine, Paroxetine) or **CYP3A4** inhibitors (Clarithromycin) require the Aripiprazole dose to be halved.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Carbamazepine/Phenytoin (CYP inducers) will wipe out Aripiprazole levels; dose must be doubled.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for Akathisia. If the patient is constantly pacing or rocking from foot to foot, they need dose reduction, Propranolol, or a medication switch.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Baseline **BSL** and **Lipids** (though lowest risk).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Prolactin Fix", + "val": "Because Aripiprazole is a partial dopamine agonist, it stimulates the pituitary to stop making prolactin. It is often co-prescribed with Risperidone or Haloperidol specifically to reverse their hyperprolactinemia side effects.", + "tags": [] + }, + { + "key": "Morning Dosing", + "val": "Unlike Olanzapine or Quetiapine, Aripiprazole is activating. It should be taken in the morning, otherwise the patient will suffer severe insomnia.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Partial agonist at D2 and 5-HT1A receptors, and antagonist at 5-HT2A. Acts as a 'dopamine stabilizer'—blocks D2 when dopamine is too high (psychosis), but stimulates D2 when dopamine is too low (depression/negative symptoms).", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Steady state takes 14 days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "75 hours. (Metabolised by CYP2D6 and CYP3A4).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ABILIFY oral ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Partial Agonist — Unique 'third-generation' antipsychotic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (2 mg to 30 mg). (Abilify, Abilify Maintena (LAI))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10-15 mg **OD** (morning). Max 30 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia: **PO** 10-15 mg **OD** (morning). Max 30 mg/day. Bipolar Maintenance: **PO** 15 mg **OD**. Adjunct for Depression: **PO** 2-5 mg **OD** (Off-label). Elderly / Frail: **PO** 5-10 mg **OD** (morning). Max **10 mg/day** in elderly. Lower starting dose preferred due to akathisia risk." + }, + { + "label": "Best Uses", + "value": "Aripiprazole is a unique partial dopamine agonist antipsychotic with the lowest metabolic risk in its class, but can cause paradoxical akathisia and activation early in treatment." + }, + { + "label": "Avoid / Cautions", + "value": "Known severe hypersensitivity. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Akathisia (intense, agonizing inner restlessness and inability to sit still). Often mistaken for worsening agitation. HIGH — Insomnia, activating effects. Metabolic: Highly weight-neutral, zero prolactin elevation (in fact, it lowers prolactin). Psychiatric: Impulse control disorders (gambling, hypersexuality) due to partial D2 agonism in the reward pathways." + }, + { + "label": "Key Interactions", + "value": "**CYP2D6** inhibitors (Fluoxetine, Paroxetine) or **CYP3A4** inhibitors (Clarithromycin) require the Aripiprazole dose to be halved. Carbamazepine/Phenytoin (CYP inducers) will wipe out Aripiprazole levels; dose must be doubled." + }, + { + "label": "Monitoring", + "value": "Monitor for Akathisia. If the patient is constantly pacing or rocking from foot to foot, they need dose reduction, Propranolol, or a medication switch. Baseline **BSL** and **Lipids** (though lowest risk)." + }, + { + "label": "Clinical Pearl", + "value": "Because Aripiprazole is a partial dopamine agonist, it stimulates the pituitary to stop making prolactin. It is often co-prescribed with Risperidone or Haloperidol specifically to reverse their hyperprolactinemia side effects." + } + ] + }, + { + "slug": "clozapine", + "name": "Clozapine", + "class": "Antipsychotic", + "subclass": "SGA / Dibenzodiazepine", + "category": "Psychiatry - Antipsychotics", + "accent": "#059669", + "tag": "SGA / TRS", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "900 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Neutrophils", + "value": "STRICT LIMITS", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Myocarditis", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Constipation", + "value": "FATAL RISK", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The most effective antipsychotic in existence. Reserved exclusively for Treatment-Resistant Schizophrenia (TRS). Fraught with lethal toxicities requiring intense national monitoring (CPMS).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **900 mg/day** (Requires very slow, heavily monitored titration).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Lethal side effects include agranulocytosis, myocarditis, and fatal paralytic ileus (constipation). Never initiate outside a strictly controlled psychiatric setting.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Clozapine is the most effective antipsychotic for treatment-resistant schizophrenia, but requires mandatory regular blood monitoring due to risk of fatal agranulocytosis and causes severe metabolic syndrome.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Agranulocytosis (1-2% risk, fatal if unmonitored).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CRITICAL — Myocarditis and Cardiomyopathy (highest risk in first 4-8 weeks), severe orthostatic hypotension, tachycardia.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "CRITICAL — Hypomotility leading to toxic megacolon, bowel ischemia, and fatal paralytic ileus. Severe hypersalivation (drooling).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Dose-dependent seizures (especially > 600mg/day), profound sedation.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Extreme weight gain, diabetes.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Treatment Resistant Schizophrenia", + "val": "Start **PO** 12.5 mg ONCE or TWICE daily. Titrate up by 25-50 mg/day as tolerated. Target 300-450 mg/day. Max 900 mg/day.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "Start **PO** 6.25 - 12.5 mg **NOCTE**. Titrate extremely slowly. Max **200 mg/day** in elderly (extreme seizure and agranulocytosis risk at higher doses).", + "tags": [] + }, + { + "key": "Missed Dose Rule", + "val": "MANDATORY — If a patient misses exactly 48 HOURS of Clozapine, they lose their tolerance. You CANNOT restart their normal dose (it will cause cardiovascular collapse). You must re-titrate from 12.5 mg.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Clozaril, Clopine", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (12.5, 25, 50, 100, 200 mg). Oral liquid.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Highly Restricted. Prescriber, Pharmacist, and Patient MUST be registered with the Clozapine Patient Monitoring System (CPMS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Treatment-resistant schizophrenia, reduction of suicidal behavior in schizophrenia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The absolute last line of defense. The only antipsychotic proven to significantly reduce suicide rates.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of clozapine-induced agranulocytosis or myocarditis. Uncontrolled epilepsy. Paralytic ileus.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Clozapine pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Smoking. Cigarette smoke heavily induces CYP1A2. If a patient stops smoking (e.g., admitted to hospital), their Clozapine levels will DOUBLE, causing seizures and coma. Dose must be reduced rapidly.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Ciprofloxacin and Fluvoxamine (potent CYP1A2 inhibitors) spike clozapine levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Strict **FBC** monitoring via CPMS (Weekly for 18 weeks, then 4-weekly). Baseline and ongoing Troponin/CRP to monitor for myocarditis.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Bowel chart tracking. Constipation on clozapine is a medical emergency. Check **HR**, **BP**, and temperature daily during titration.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Constipation Killer", + "val": "More patients die from clozapine-induced bowel ischemia (constipation) than from agranulocytosis. Every patient must be prescribed prophylactic laxatives (e.g., Movicol + Senna). Do not ignore a clozapine patient who hasn't opened their bowels in 3 days.", + "tags": [] + }, + { + "key": "The Drool Paradox", + "val": "Despite being highly anticholinergic (which normally causes dry mouth), Clozapine causes profound hypersalivation. Patients often need atropine drops or ipratropium spray sublingually to stop them choking on their own saliva at night.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Unique profile. Very loose binding to D2 (zero EPS/Parkinsonism). Potent antagonist at 5-HT2A, Alpha-1, H1, and Muscarinic (M1) receptors.", + "tags": [] + }, + { + "key": "Onset", + "val": "Sedation is rapid. Antipsychotic efficacy takes weeks to months.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12-16 hours. Metabolised primarily by **CYP1A2**.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CLOZARIL/CLOPINE ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Dibenzodiazepine — The most effective antipsychotic in existence." + }, + { + "label": "Route / Formulation", + "value": "Tablets (12.5, 25, 50, 100, 200 mg). Oral liquid. (Clozaril, Clopine)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 12.5 mg ONCE or TWICE daily. Titrate up by 25-50 mg/day as tolerated. Target 300-450 mg/day. Max 900 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Treatment Resistant Schizophrenia: Start **PO** 12.5 mg ONCE or TWICE daily. Titrate up by 25-50 mg/day as tolerated. Target 300-450 mg/day. Max 900 mg/day. Elderly / Frail: Start **PO** 6.25 - 12.5 mg **NOCTE**. Titrate extremely slowly. Max **200 mg/day** in elderly (extreme seizure and agranulocytosis risk at higher doses). Missed Dose Rule: If a patient misses exactly 48 HOURS of Clozapine, they lose their tolerance. You CANNOT restart their normal dose (it will cause cardiovascular collapse). You must re-titrate from 12.5 mg." + }, + { + "label": "Best Uses", + "value": "Clozapine is the most effective antipsychotic for treatment-resistant schizophrenia, but requires mandatory regular blood monitoring due to risk of fatal agranulocytosis and causes severe metabolic syndrome." + }, + { + "label": "Avoid / Cautions", + "value": "History of clozapine-induced agranulocytosis or myocarditis. Uncontrolled epilepsy. Paralytic ileus. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Haematological: Agranulocytosis (1-2% risk, fatal if unmonitored). Cardiovascular: Myocarditis and Cardiomyopathy (highest risk in first 4-8 weeks), severe orthostatic hypotension, tachycardia. Gastrointestinal: Hypomotility leading to toxic megacolon, bowel ischemia, and fatal paralytic ileus. Severe hypersalivation (drooling). Neurological: Dose-dependent seizures (especially > 600mg/day), profound sedation." + }, + { + "label": "Key Interactions", + "value": "Smoking. Cigarette smoke heavily induces CYP1A2. If a patient stops smoking (e.g., admitted to hospital), their Clozapine levels will DOUBLE, causing seizures and coma. Dose must be reduced rapidly. Ciprofloxacin and Fluvoxamine (potent CYP1A2 inhibitors) spike clozapine levels." + }, + { + "label": "Monitoring", + "value": "Strict **FBC** monitoring via CPMS (Weekly for 18 weeks, then 4-weekly). Baseline and ongoing Troponin/CRP to monitor for myocarditis. Bowel chart tracking. Constipation on clozapine is a medical emergency. Check **HR**, **BP**, and temperature daily during titration." + }, + { + "label": "Clinical Pearl", + "value": "More patients die from clozapine-induced bowel ischemia (constipation) than from agranulocytosis. Every patient must be prescribed prophylactic laxatives (e.g., Movicol + Senna). Do not ignore a clozapine patient who hasn't opened their bowels in 3 days." + } + ] + }, + { + "slug": "olanzapine-wafer-odt", + "name": "Olanzapine (wafer/ODT)", + "class": "Antipsychotic", + "subclass": "SGA / Thienobenzodiazepine", + "category": "Psychiatry - Antipsychotics", + "accent": "#059669", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "33 h", + "cls": "", + "flag": "" + }, + { + "label": "Metabolic", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Sedation", + "value": "SEVERE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Second-Generation Antipsychotic (SGA). Highly sedating, rapidly acting agent. Excellent for acute agitation, but notorious for causing massive weight gain and metabolic syndrome.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day** (Higher doses only under strict psychiatric direction).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never administer IM Olanzapine within 1-2 hours of IM Benzodiazepines due to a severe risk of fatal respiratory depression and bradycardia.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Olanzapine (wafer/ODT) is a highly effective rapidly-dissolving antipsychotic for acute agitation and psychosis, but causes significant metabolic syndrome including weight gain and diabetes with ongoing use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Massive weight gain, new-onset type 2 diabetes, severe hyperlipidemia.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Profound sedation, somnolence, anticholinergic delirium (in the elderly).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Orthostatic hypotension, **QTc** prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Agitation", + "val": "**PO** 5-10 mg Wafer STAT. May repeat after 2 hours. Max 20 mg/day.", + "tags": [] + }, + { + "key": "Schizophrenia / Bipolar", + "val": "**PO** 5-10 mg **NOCTE**. Titrate up to 20 mg/day.", + "tags": [] + }, + { + "key": "Elderly / Delirium", + "val": "**PO** 2.5 mg Wafer STAT. Max **5 mg/day** in elderly. Extremely sensitive to sedation and anticholinergic effects.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zyprexa, Zypine ODT", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (2.5 mg, 5 mg, 10 mg). Wafers/ODT (5 mg, 10 mg) - melt on tongue instantly.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IM** injection (Short-acting) and **IM** Depot (Relprevv).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia, Bipolar I mania.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Acute severe agitation, severe refractory nausea, delirium.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The go-to oral 'rescue' medication on wards (as a wafer) due to rapid absorption and intense sedation.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent use of IM Olanzapine and IM Benzodiazepines.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C (High risk of gestational diabetes and macrosomia).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Olanzapine (wafer/ODT) pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — CNS Depressants (Opioids, Benzos). Massive risk of respiratory collapse.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Smoking. Polycyclic aromatic hydrocarbons in cigarette smoke induce CYP1A2. If a patient stops smoking in hospital, their Olanzapine levels will artificially spike by up to 50%, causing heavy sedation.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and 3-monthly **BSL**, **HbA1c**, **Lipids**, and **Weight**.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Baseline **ECG** for QTc assessment.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Wafer Illusion", + "val": "Wafers dissolve in the mouth, preventing the patient from 'cheeking' the pill and spitting it out. However, they are NOT absorbed through the mouth; the dissolved saliva must still be swallowed to be absorbed in the gut.", + "tags": [] + }, + { + "key": "The Smoking Trap", + "val": "Always ask about smoking status. If a heavily smoking psychiatric patient is admitted to a smoke-free ward, their CYP1A2 enzyme slows down. Their usual 20mg dose of Olanzapine will now act like 30mg, heavily over-sedating them.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Broad multi-receptor antagonist. Blocks dopamine (D2), serotonin (5-HT2A), histamine (H1), and muscarinic (M1) receptors. The H1 blockade causes profound sedation and appetite stimulation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** (Wafer) 15-30 mins. **IM** 15 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "33 hours (Heavily hepatically metabolised by CYP1A2).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ZYPREXA/TOLAZE ODT ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Thienobenzodiazepine — Second-Generation Antipsychotic (SGA)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (2.5 mg, 5 mg, 10 mg). Wafers/ODT (5 mg, 10 mg) - melt on tongue instantly. (Zyprexa, Zypine ODT)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5-10 mg Wafer STAT. May repeat after 2 hours. Max 20 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Acute Agitation: **PO** 5-10 mg Wafer STAT. May repeat after 2 hours. Max 20 mg/day. Schizophrenia / Bipolar: **PO** 5-10 mg **NOCTE**. Titrate up to 20 mg/day. Elderly / Delirium: **PO** 2.5 mg Wafer STAT. Max **5 mg/day** in elderly. Extremely sensitive to sedation and anticholinergic effects." + }, + { + "label": "Best Uses", + "value": "Olanzapine (wafer/ODT) is a highly effective rapidly-dissolving antipsychotic for acute agitation and psychosis, but causes significant metabolic syndrome including weight gain and diabetes with ongoing use." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of IM Olanzapine and IM Benzodiazepines. **Pregnancy** Category C (High risk of gestational diabetes and macrosomia)." + }, + { + "label": "Key Risks", + "value": "Metabolic: Massive weight gain, new-onset type 2 diabetes, severe hyperlipidemia. Neurological: Profound sedation, somnolence, anticholinergic delirium (in the elderly). Cardiovascular: Orthostatic hypotension, **QTc** prolongation." + }, + { + "label": "Key Interactions", + "value": "CNS Depressants (Opioids, Benzos). Massive risk of respiratory collapse. Smoking. Polycyclic aromatic hydrocarbons in cigarette smoke induce CYP1A2. If a patient stops smoking in hospital, their Olanzapine levels will artificially spike by up to 50%, causing heavy sedation." + }, + { + "label": "Monitoring", + "value": "Baseline and 3-monthly **BSL**, **HbA1c**, **Lipids**, and **Weight**. Baseline **ECG** for QTc assessment." + }, + { + "label": "Clinical Pearl", + "value": "Wafers dissolve in the mouth, preventing the patient from 'cheeking' the pill and spitting it out. However, they are NOT absorbed through the mouth; the dissolved saliva must still be swallowed to be absorbed in the gut." + } + ] + }, + { + "slug": "quetiapine", + "name": "Quetiapine", + "class": "Antipsychotic", + "subclass": "SGA / Dibenzothiazepine", + "category": "Psychiatry - Antipsychotics", + "accent": "#059669", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "800 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "7 h", + "cls": "", + "flag": "" + }, + { + "label": "Sedation", + "value": "SEVERE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Orthostasis", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "SGA with extremely strong histamine and alpha-1 blockade. Functions as a potent sedative at low doses, an antidepressant at moderate doses, and an antipsychotic at high doses.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **800 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Severe risk of orthostatic hypotension and falls, particularly when initiating or escalating the dose.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Quetiapine is a widely prescribed atypical antipsychotic used across psychosis, bipolar, and off-label insomnia, but causes significant metabolic effects and sedation, and off-label low-dose use should be critically reviewed.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Orthostatic hypotension, tachycardia, **QTc** prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "HIGH — Somnolence, dizziness, 'hangover' effect.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Weight gain, hyperglycemia, hyperlipidemia (second only to Olanzapine/Clozapine).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Insomnia / Anxiety (Off-Label)", + "val": "**PO** 12.5 - 25 mg **NOCTE**.", + "tags": [] + }, + { + "key": "Bipolar Depression", + "val": "**PO** 300 mg **NOCTE** (Often using XR formulations).", + "tags": [] + }, + { + "key": "Schizophrenia / Mania", + "val": "**PO** 400 - 800 mg/day in divided doses or as a single XR dose at night.", + "tags": [] + }, + { + "key": "Elderly", + "val": "Start at 12.5 mg **NOCTE**. Max **100 mg/day** in elderly. Highly sensitive to alpha-1 mediated falls.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Seroquel, Seroquel XR", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "IR Tablets (25, 100, 200, 300 mg). XR Tablets (50, 150, 200, 300, 400 mg). Do NOT crush XR.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia, Bipolar mania, Bipolar depression.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Severe insomnia, borderline personality disorder, generalized anxiety.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The most widely prescribed 'off-label' sedative in hospitals. Essential for Bipolar depression.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent use of strong CYP3A4 inhibitors (Clarithromycin, Ketoconazole).", + "tags": [], + "patient": { + "factors": ["allergy-macrolide"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Elderly & Dementia", + "val": "CAUTION — Black box warning for increased mortality in dementia-related psychosis.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — **CYP3A4** inhibitors massively spike Quetiapine levels, causing profound sedation, coma, and QTc prolongation. CYP3A4 inducers (Phenytoin) render it useless.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive hypotension with antihypertensives.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Postural **BP** checks for the first 3 days of therapy or upon dose increase.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Baseline **BSL**, **HbA1c**, **Lipids**, and **Weight**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Dose-Dependent Paradigm", + "val": "Quetiapine is 3 different drugs depending on the dose. At 25mg, it only blocks histamine (it's a sleeping pill). At 300mg, it blocks NET and 5HT2A (it's an antidepressant). You must hit 400-800mg to reliably block D2 receptors (it becomes an antipsychotic).", + "tags": [] + }, + { + "key": "The XR Trap", + "val": "Seroquel XR must be taken on an empty stomach or a light meal. A heavy, high-fat dinner destroys the sustained-release matrix, causing a massive 'dose dump' leading to sudden orthostatic collapse.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Rapidly dissociating D2 antagonist (lowest risk of EPS among SGAs). Potent H1 antagonist (sedation) and Alpha-1 antagonist (hypotension). Active metabolite (norquetiapine) acts as a NET inhibitor (antidepressant effect).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins (IR).", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "7 hours. Hepatically metabolised by CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - SEROQUEL ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Dibenzothiazepine — SGA with extremely strong histamine and alpha-1 blockade." + }, + { + "label": "Route / Formulation", + "value": "IR Tablets (25, 100, 200, 300 mg). XR Tablets (50, 150, 200, 300, 400 mg). Do NOT crush XR. (Seroquel, Seroquel XR)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 12.5 - 25 mg **NOCTE**. Max **800 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Insomnia / Anxiety (Off-Label): **PO** 12.5 - 25 mg **NOCTE**. Bipolar Depression: **PO** 300 mg **NOCTE** (Often using XR formulations). Schizophrenia / Mania: **PO** 400 - 800 mg/day in divided doses or as a single XR dose at night. Elderly: Start at 12.5 mg **NOCTE**. Max **100 mg/day** in elderly. Highly sensitive to alpha-1 mediated falls." + }, + { + "label": "Best Uses", + "value": "Quetiapine is a widely prescribed atypical antipsychotic used across psychosis, bipolar, and off-label insomnia, but causes significant metabolic effects and sedation, and off-label low-dose use should be critically reviewed." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of strong CYP3A4 inhibitors (Clarithromycin, Ketoconazole)." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Orthostatic hypotension, tachycardia, **QTc** prolongation. Neurological: Somnolence, dizziness, 'hangover' effect. Metabolic: Weight gain, hyperglycemia, hyperlipidemia (second only to Olanzapine/Clozapine)." + }, + { + "label": "Key Interactions", + "value": "**CYP3A4** inhibitors massively spike Quetiapine levels, causing profound sedation, coma, and QTc prolongation. CYP3A4 inducers (Phenytoin) render it useless. Additive hypotension with antihypertensives." + }, + { + "label": "Monitoring", + "value": "Postural **BP** checks for the first 3 days of therapy or upon dose increase. Baseline **BSL**, **HbA1c**, **Lipids**, and **Weight**." + }, + { + "label": "Clinical Pearl", + "value": "Quetiapine is 3 different drugs depending on the dose. At 25mg, it only blocks histamine (it's a sleeping pill). At 300mg, it blocks NET and 5HT2A (it's an antidepressant). You must hit 400-800mg to reliably block D2 receptors (it becomes an antipsychotic)." + } + ] + }, + { + "slug": "risperidone", + "name": "Risperidone", + "class": "Antipsychotic", + "subclass": "SGA / Benzisoxazole", + "category": "Psychiatry - Antipsychotics", + "accent": "#059669", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "8 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "20 h", + "cls": "", + "flag": "" + }, + { + "label": "Prolactin", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "EPS Risk", + "value": "DOSE-DEP", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent D2 and 5-HT2A antagonist. At low doses, it acts like a modern SGA. At high doses (>4mg), it acts like an older typical antipsychotic, causing severe EPS.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **8 mg/day** (Doses > 6 mg carry severe EPS risks with minimal extra benefit).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The most notorious SGA for causing hyperprolactinemia (galactorrhea, gynecomastia, amenorrhea).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Risperidone is a potent D2/5-HT2A antagonist effective for psychosis and behavioural disturbance, but causes dose-dependent hyperprolactinaemia and extrapyramidal symptoms more than other atypicals.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — Hyperprolactinemia (causes milk production, loss of periods, sexual dysfunction, and long-term osteoporosis).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Extrapyramidal side effects (EPS) including parkinsonism and akathisia, strongly dose-dependent > 4 mg/day.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Weight gain, metabolic syndrome.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia / Bipolar", + "val": "**PO** 1 mg **BD** initially. Titrate to target 4-6 mg/day.", + "tags": [] + }, + { + "key": "BPSD (Dementia Agitation)", + "val": "**PO** 0.25 - 0.5 mg **BD**. Max **2 mg/day** in elderly/BPSD. Short-term use only.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Halve the starting dose if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Risperdal, Risperdal Consta (LAI)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (0.5 to 4 mg), ODT Wafers, Oral Liquid (1 mg/mL).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Long-Acting Injection (LAI) for IM use.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia, Bipolar mania, Behavioral and Psychological Symptoms of Dementia (BPSD), Autism irritability.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly effective for acute positive symptoms. Only SGA officially approved for BPSD in Australia.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known hypersensitivity. Severe CNS depression.", + "tags": [] + }, + { + "key": "Elderly & Dementia", + "val": "CAUTION — Black Box Warning for increased risk of stroke (CVA) and mortality in elderly patients with dementia. Use lowest dose for shortest time.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (Fluoxetine, Paroxetine, Bupropion) massively increase risperidone levels, triggering severe EPS and hyperprolactinemia.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Antihypertensives (additive hypotension).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Serum Prolactin if symptoms develop. Baseline **BSL**, **Lipids**, and **Weight**.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor for rigidity, tremor, or severe restlessness (akathisia).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Typical Atypical", + "val": "Risperidone bridges the gap between old and new antipsychotics. If you prescribe 6-8 mg of Risperidone, you are essentially prescribing Haloperidol. The patient will almost certainly require Benzatropine to counteract the severe stiffness.", + "tags": [] + }, + { + "key": "The Liquid Trap", + "val": "Risperidone oral liquid is incompatible with tea and cola (it precipitates). It must be mixed with water, orange juice, or milk.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Very tight binding to D2 (dopamine) and 5-HT2A (serotonin) receptors. Also blocks alpha-1 receptors (hypotension).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "20 hours (Active metabolite is paliperidone). Metabolised by CYP2D6.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - RISPERDAL ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Benzisoxazole — Potent D2 and 5-HT2A antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (0.5 to 4 mg), ODT Wafers, Oral Liquid (1 mg/mL). (Risperdal, Risperdal Consta (LAI))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1 mg **BD** initially. Titrate to target 4-6 mg/day. Max **8 mg/day** (Doses > 6 mg carry severe EPS risks with minimal extra benefit)." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia / Bipolar: **PO** 1 mg **BD** initially. Titrate to target 4-6 mg/day. BPSD (Dementia Agitation): **PO** 0.25 - 0.5 mg **BD**. Max **2 mg/day** in elderly/BPSD. Short-term use only. Renal Impairment: Halve the starting dose if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Risperidone is a potent D2/5-HT2A antagonist effective for psychosis and behavioural disturbance, but causes dose-dependent hyperprolactinaemia and extrapyramidal symptoms more than other atypicals." + }, + { + "label": "Avoid / Cautions", + "value": "Known hypersensitivity. Severe CNS depression." + }, + { + "label": "Key Risks", + "value": "Endocrine: Hyperprolactinemia (causes milk production, loss of periods, sexual dysfunction, and long-term osteoporosis). Neurological: Extrapyramidal side effects (EPS) including parkinsonism and akathisia, strongly dose-dependent > 4 mg/day. Metabolic: Weight gain, metabolic syndrome." + }, + { + "label": "Key Interactions", + "value": "**CYP2D6** inhibitors (Fluoxetine, Paroxetine, Bupropion) massively increase risperidone levels, triggering severe EPS and hyperprolactinemia. Antihypertensives (additive hypotension)." + }, + { + "label": "Monitoring", + "value": "Serum Prolactin if symptoms develop. Baseline **BSL**, **Lipids**, and **Weight**. Monitor for rigidity, tremor, or severe restlessness (akathisia)." + }, + { + "label": "Clinical Pearl", + "value": "Risperidone bridges the gap between old and new antipsychotics. If you prescribe 6-8 mg of Risperidone, you are essentially prescribing Haloperidol. The patient will almost certainly require Benzatropine to counteract the severe stiffness." + } + ] + }, + { + "slug": "aripiprazole-lai", + "name": "Aripiprazole LAI", + "class": "LAI Antipsychotic", + "subclass": "Abilify Depot", + "category": "Psychiatry - Depot Antipsychotics", + "accent": "#0d9488", + "tag": "DEPOT Q4W/Q8W", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg Q4W", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "30–46 Days", + "cls": "", + "flag": "" + }, + { + "label": "Akathisia", + "value": "MODERATE", + "cls": "warn", + "flag": "" + }, + { + "label": "PO Overlap", + "value": "14 DAYS", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Long-Acting Injectable (LAI) partial D2 agonist. Provides stable, 4-weekly or 8-weekly coverage for schizophrenia with an excellent metabolic profile.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mg** every 4 weeks (Abilify Maintena).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Takes weeks to reach steady state. A strict 14-day oral overlap is legally and clinically required upon initiation to prevent psychotic relapse.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Aripiprazole LAI is a long-acting injectable antipsychotic with low metabolic risk for maintenance schizophrenia treatment, but requires 2 weeks of oral supplementation at initiation and can cause injection site reactions.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Akathisia (intense inner restlessness), insomnia. Often requires propranolol to manage.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "SAFE — Lowest risk of weight gain, lipid spikes, or hyperprolactinemia among LAIs.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Minimal QTc or BP effects.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Abilify Maintena (1-Monthly)", + "val": "**IM** 400 mg every 4 weeks (Gluteal or Deltoid). Must continue oral Aripiprazole (10-20 mg/day) for 14 consecutive days after the 1st injection.", + "tags": [] + }, + { + "key": "Abilify Asimtufii (2-Monthly)", + "val": "**IM** 960 mg every 8 weeks (Gluteal ONLY).", + "tags": [] + }, + { + "key": "Missed Dose Rule", + "val": "MANDATORY — If the 2nd or 3rd dose is delayed by > 5 weeks, the patient loses coverage and MUST undergo the 14-day oral overlap again.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Abilify Maintena, Abilify Asimtufii", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Dual-chamber syringe for reconstitution. Must shake vigorously for 20 seconds immediately before **IM** injection.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Must be initiated by a Psychiatrist.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment of Schizophrenia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Preferred depot for young, metabolically vulnerable patients or those who experienced severe weight gain on Invega/Zyprexa.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known hypersensitivity. Do not administer IV or SC.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "CAUTION — Avoid if severe hepatic impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong **CYP3A4** inhibitors (Clarithromycin) or **CYP2D6** inhibitors (Fluoxetine) require the depot dose to be reduced to 300 mg.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Strong CYP inducers (Carbamazepine) will destroy depot blood levels. Avoid combination.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure strict compliance with the 14-day oral overlap. Give the injection deep into the muscle to prevent sterile abscesses.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Baseline **BSL**, **Lipids**, and **Weight**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Shake Rule", + "val": "The suspension settles instantly. If the nurse reconstitutes the syringe, puts it down for 5 minutes to talk to the patient, and then injects it without re-shaking, the needle will block, ruining a $400 injection.", + "tags": [] + }, + { + "key": "The Activation Shift", + "val": "Aripiprazole is highly activating. Administering the depot may cause the patient to experience severe insomnia for the first few nights compared to sedating depots like Zuclopenthixol.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Slow-release depot of aripiprazole. Partial agonist at D2 and 5-HT1A, antagonist at 5-HT2A. 'Dopamine stabilizer'.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Steady state achieved after 4 injections.", + "tags": [] + }, + { + "key": "Half-life", + "val": "30-46 Days (Massive depot tail).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ABILIFY MAINTENA/ASIMTUFII ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Abilify Depot — Long-Acting Injectable (LAI) partial D2 agonist." + }, + { + "label": "Route / Formulation", + "value": "Dual-chamber syringe for reconstitution. Must shake vigorously for 20 seconds immediately before **IM** injection. (Abilify Maintena, Abilify Asimtufii)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 400 mg every 4 weeks (Gluteal or Deltoid). Must continue oral Aripiprazole (10-20 mg/day) for 14 consecutive days after the 1st injection. Max **400 mg** every 4 weeks (Abilify Maintena)." + }, + { + "label": "Key Indication Doses", + "value": "Abilify Maintena (1-Monthly): **IM** 400 mg every 4 weeks (Gluteal or Deltoid). Must continue oral Aripiprazole (10-20 mg/day) for 14 consecutive days after the 1st injection. Abilify Asimtufii (2-Monthly): **IM** 960 mg every 8 weeks (Gluteal ONLY). Missed Dose Rule: If the 2nd or 3rd dose is delayed by > 5 weeks, the patient loses coverage and MUST undergo the 14-day oral overlap again." + }, + { + "label": "Best Uses", + "value": "Aripiprazole LAI is a long-acting injectable antipsychotic with low metabolic risk for maintenance schizophrenia treatment, but requires 2 weeks of oral supplementation at initiation and can cause injection site reactions." + }, + { + "label": "Avoid / Cautions", + "value": "Known hypersensitivity. Do not administer IV or SC." + }, + { + "label": "Key Risks", + "value": "Neurological: Akathisia (intense inner restlessness), insomnia. Often requires propranolol to manage. Metabolic: Lowest risk of weight gain, lipid spikes, or hyperprolactinemia among LAIs. Cardiovascular: Minimal QTc or BP effects." + }, + { + "label": "Key Interactions", + "value": "Strong **CYP3A4** inhibitors (Clarithromycin) or **CYP2D6** inhibitors (Fluoxetine) require the depot dose to be reduced to 300 mg. Strong CYP inducers (Carbamazepine) will destroy depot blood levels. Avoid combination." + }, + { + "label": "Monitoring", + "value": "Ensure strict compliance with the 14-day oral overlap. Give the injection deep into the muscle to prevent sterile abscesses. Baseline **BSL**, **Lipids**, and **Weight**." + }, + { + "label": "Clinical Pearl", + "value": "The suspension settles instantly. If the nurse reconstitutes the syringe, puts it down for 5 minutes to talk to the patient, and then injects it without re-shaking, the needle will block, ruining a $400 injection." + } + ] + }, + { + "slug": "flupentixol-decanoate", + "name": "Flupentixol decanoate", + "class": "LAI Antipsychotic", + "subclass": "FGA Depot", + "category": "Psychiatry - Depot Antipsychotics", + "accent": "#0d9488", + "tag": "DEPOT Q2-4W", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "40 mg/week", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "17 Days", + "cls": "", + "flag": "" + }, + { + "label": "Activation", + "value": "HIGH", + "cls": "warn", + "flag": "" + }, + { + "label": "EPS Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "First-Generation Antipsychotic (FGA) depot. Extremely potent D2 antagonist. Uniquely activating and alerting, making it excellent for withdrawn, apathetic patients, but terrible for agitated ones.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **40 mg/week** (Usually dosed 20-40 mg every 2-4 weeks).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "High risk of severe EPS. Often exacerbates anxiety or agitation if given to the wrong patient type.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Flupentixol decanoate is a depot thioxanthene antipsychotic for maintenance treatment of schizophrenia, but causes extrapyramidal effects and depression can emerge, and effects persist for weeks after injection.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Severe Extrapyramidal Side Effects (Parkinsonism, acute dystonia, severe akathisia). HIGH — Insomnia, agitation, over-stimulation.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — **QTc** prolongation, mild tachycardia.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Endocrine", + "val": "MODERATE — Hyperprolactinemia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia Maintenance", + "val": "**IM** 20-40 mg every 2 to 4 weeks. Deep gluteal injection (Z-Track method).", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Start with 10-20 mg every 4 weeks. Highly sensitive to EPS.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Fluanxol Depot", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (20 mg/1 mL). Thin oil suspension.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment of Schizophrenia, especially in patients with prominent negative symptoms (apathy, withdrawal).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The direct opposite of Zuclopenthixol (Clopixol). Clopixol puts you to sleep; Fluanxol wakes you up.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severely agitated or hyperactive patients, Parkinson's disease, severe CNS depression.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Flupentixol decanoate pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Avoid concurrent QTc prolonging drugs.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (Paroxetine) spike Flupentixol levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for akathisia (pacing/restlessness). If the patient complains of severe anxiety post-injection, it is likely akathisia. Treat with Propranolol.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Baseline **ECG** (QTc check).", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Depot Pair", + "val": "Flupentixol and Zuclopenthixol are sister drugs. Remember: Flupentixol = Fly (Activating/Energy). Zuclopenthixol = Zzz (Sleeping/Sedating). Choose the depot based on whether the patient is withdrawn or aggressive.", + "tags": [] + }, + { + "key": "The Z-Track Necessity", + "val": "Must be injected deep IM using the Z-Track method to trap the oil in the muscle and prevent painful sterile subcutaneous abscesses.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Thioxanthene derivative. Esterified with decanoic acid. At low doses, it blocks presynaptic D2 autoreceptors (boosting dopamine release, causing activation). At higher doses, it blocks postsynaptic D2 receptors (antipsychotic effect).", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Steady state takes 3 months.", + "tags": [] + }, + { + "key": "Half-life", + "val": "17 Days (Released slowly from the oil depot).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - FLUANXOL DEPOT ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "FGA Depot — First-Generation Antipsychotic (FGA) depot." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (20 mg/1 mL). Thin oil suspension. (Fluanxol Depot)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 20-40 mg every 2 to 4 weeks. Deep gluteal injection (Z-Track method). Max **40 mg/week** (Usually dosed 20-40 mg every 2-4 weeks)." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia Maintenance: **IM** 20-40 mg every 2 to 4 weeks. Deep gluteal injection (Z-Track method). Elderly / Frail: Start with 10-20 mg every 4 weeks. Highly sensitive to EPS." + }, + { + "label": "Best Uses", + "value": "Flupentixol decanoate is a depot thioxanthene antipsychotic for maintenance treatment of schizophrenia, but causes extrapyramidal effects and depression can emerge, and effects persist for weeks after injection." + }, + { + "label": "Avoid / Cautions", + "value": "Severely agitated or hyperactive patients, Parkinson's disease, severe CNS depression. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Severe Extrapyramidal Side Effects (Parkinsonism, acute dystonia, severe akathisia). HIGH — Insomnia, agitation, over-stimulation. Cardiovascular: **QTc** prolongation, mild tachycardia. Endocrine: Hyperprolactinemia." + }, + { + "label": "Key Interactions", + "value": "Avoid concurrent QTc prolonging drugs. **CYP2D6** inhibitors (Paroxetine) spike Flupentixol levels." + }, + { + "label": "Monitoring", + "value": "Monitor for akathisia (pacing/restlessness). If the patient complains of severe anxiety post-injection, it is likely akathisia. Treat with Propranolol. Baseline **ECG** (QTc check)." + }, + { + "label": "Clinical Pearl", + "value": "Flupentixol and Zuclopenthixol are sister drugs. Remember: Flupentixol = Fly (Activating/Energy). Zuclopenthixol = Zzz (Sleeping/Sedating). Choose the depot based on whether the patient is withdrawn or aggressive." + } + ] + }, + { + "slug": "haloperidol-decanoate", + "name": "Haloperidol decanoate", + "class": "LAI Antipsychotic", + "subclass": "FGA Depot", + "category": "Psychiatry - Depot Antipsychotics", + "accent": "#0d9488", + "tag": "DEPOT Q4W", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg Q4W", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3 Weeks", + "cls": "", + "flag": "" + }, + { + "label": "EPS Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Z-Track IM", + "value": "REQUIRED", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "First-Generation Antipsychotic (FGA) depot. Extremely potent D2 antagonist dissolved in sesame oil. Highly effective for treatment-resistant positive symptoms but carries brutal EPS risks.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg** every 4 weeks (Doses > 100 mg are rarely needed and highly toxic).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Because it is oil-based, it MUST be injected using the Z-Track method to prevent the oil leaking back into the subcutaneous fat and causing tissue necrosis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Haloperidol decanoate is a first-generation long-acting injectable antipsychotic for chronic schizophrenia, but causes significant extrapyramidal side effects and tardive dyskinesia with long-term use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Severe Extrapyramidal Side Effects (Parkinsonism, acute dystonia, severe akathisia). Tardive Dyskinesia risk is very high. Neuroleptic Malignant Syndrome (NMS).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — **QTc** prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Endocrine", + "val": "MODERATE — Hyperprolactinemia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia", + "val": "**IM** 50-100 mg every 4 weeks. Deep gluteal injection.", + "tags": [] + }, + { + "key": "Initiation", + "val": "Calculate total daily oral dose, multiply by 10-15 to get the monthly depot dose. Requires PO overlap for 2-3 weeks.", + "tags": [] + }, + { + "key": "Elderly", + "val": "MANDATORY — Max 12.5 - 25 mg every 4 weeks. Extremely sensitive to EPS.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Haldol Decanoate", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (50 mg/1 mL, 100 mg/1 mL). Thick oil solution.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment of Schizophrenia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Reserved for older patients stabilized on it for decades, or highly severe psychotic patients who fail SGAs. Almost never used as a first-line depot today.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Parkinson's disease, severe CNS depression, sesame oil allergy.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Haloperidol decanoate pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Avoid concurrent QTc prolonging drugs (e.g., Amiodarone, Macrolides).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong **CYP2D6** or **CYP3A4** inhibitors significantly raise haloperidol levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for EPS (stiffness, tremor). A PRN anticholinergic (Benzatropine) should be charted when initiating.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Baseline **ECG** (QTc check) before first injection.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Z-Track Necessity", + "val": "Because the carrier is sesame oil, if you inject straight in and pull the needle out, the oil will track back up the needle hole into the subcutaneous fat, causing a painful sterile abscess. You MUST pull the skin to the side (Z-Track), inject, wait 10 seconds, pull the needle out, and let the skin slide back to 'trap' the oil in the muscle.", + "tags": [] + }, + { + "key": "The Volume Limit", + "val": "Never inject more than 3 mL of oil into a single gluteal site. If the dose requires 4 mL, split it into two separate injections in different glutes.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Esterification with decanoic acid makes it highly lipophilic. Slowly leaches from the muscle depot into the blood, where esterases cleave the decanoate to release active haloperidol. Potent D2 blockade.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Steady state takes 3 months (3-4 injection cycles).", + "tags": [] + }, + { + "key": "Half-life", + "val": "3 Weeks.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - HALDOL DECANOATE ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "FGA Depot — First-Generation Antipsychotic (FGA) depot." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (50 mg/1 mL, 100 mg/1 mL). Thick oil solution. (Haldol Decanoate)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 50-100 mg every 4 weeks. Deep gluteal injection. Max **300 mg** every 4 weeks (Doses > 100 mg are rarely needed and highly toxic)." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia: **IM** 50-100 mg every 4 weeks. Deep gluteal injection. Initiation: Calculate total daily oral dose, multiply by 10-15 to get the monthly depot dose. Requires PO overlap for 2-3 weeks. Elderly: Max 12.5 - 25 mg every 4 weeks. Extremely sensitive to EPS." + }, + { + "label": "Best Uses", + "value": "Haloperidol decanoate is a first-generation long-acting injectable antipsychotic for chronic schizophrenia, but causes significant extrapyramidal side effects and tardive dyskinesia with long-term use." + }, + { + "label": "Avoid / Cautions", + "value": "Parkinson's disease, severe CNS depression, sesame oil allergy. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Severe Extrapyramidal Side Effects (Parkinsonism, acute dystonia, severe akathisia). Tardive Dyskinesia risk is very high. Neuroleptic Malignant Syndrome (NMS). Cardiovascular: **QTc** prolongation. Endocrine: Hyperprolactinemia." + }, + { + "label": "Key Interactions", + "value": "Avoid concurrent QTc prolonging drugs (e.g., Amiodarone, Macrolides). Strong **CYP2D6** or **CYP3A4** inhibitors significantly raise haloperidol levels." + }, + { + "label": "Monitoring", + "value": "Monitor for EPS (stiffness, tremor). A PRN anticholinergic (Benzatropine) should be charted when initiating. Baseline **ECG** (QTc check) before first injection." + }, + { + "label": "Clinical Pearl", + "value": "Because the carrier is sesame oil, if you inject straight in and pull the needle out, the oil will track back up the needle hole into the subcutaneous fat, causing a painful sterile abscess. You MUST pull the skin to the side (Z-Track), inject, wait 10 seconds, pull the needle out, and let the skin slide back to 'trap' the oil in the muscle." + } + ] + }, + { + "slug": "olanzapine-pamoate-lai", + "name": "Olanzapine pamoate LAI", + "class": "LAI Antipsychotic", + "subclass": "Zyprexa Relprevv", + "category": "Psychiatry - Depot Antipsychotics", + "accent": "#0d9488", + "tag": "DEPOT Q2-4W", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "300 mg Q2W", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "30 Days", + "cls": "", + "flag": "" + }, + { + "label": "PDSS Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Monitoring", + "value": "3 HOURS", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "A depot formulation of Olanzapine. Exceptional efficacy, but restricted by one of the most intense and dangerous post-injection monitoring protocols in modern psychiatry.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **300 mg** every 2 weeks or **405 mg** every 4 weeks.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Can cause Post-Injection Delirium/Sedation Syndrome (PDSS), where the drug accidentally hits a blood vessel, inducing a sudden, profound coma.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Olanzapine pamoate LAI is a long-acting injectable olanzapine for treatment-resistant schizophrenia, but carries unique post-injection delirium/sedation syndrome (PDSS) requiring 3-hour observation.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Post-Injection Delirium/Sedation Syndrome (PDSS). Presents within 1-3 hours of injection as severe ataxia, delirium, excessive sedation, and coma. Caused by accidental intravascular entry of the suspension.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "CRITICAL — Massive weight gain, new-onset diabetes, extreme hyperlipidemia.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Constipation, dry mouth.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia Maintenance", + "val": "**IM** 150-300 mg every 2 weeks, or 300-405 mg every 4 weeks. Deep gluteal injection ONLY.", + "tags": [] + }, + { + "key": "Initiation", + "val": "No oral overlap is strictly required if target depot doses are used, though 1-2 days of oral is often given to confirm tolerance.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zyprexa Relprevv", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Powder for reconstitution. Forms a thick yellow suspension.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS). Must be administered in a registered healthcare facility with resuscitation equipment.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment of Schizophrenia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Reserved for severely non-compliant patients who respond brilliantly to oral olanzapine but fail on other depots. The strict monitoring limits its use in the community.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Unmonitored administration environments. Severe CNS depression. Acute narrow-angle glaucoma.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Olanzapine pamoate LAI pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Benzodiazepines/Opioids (Additive severe CNS depression).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Smoking induces CYP1A2, accelerating olanzapine clearance.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — The patient MUST remain in the clinic/ward and be physically observed by a nurse every 30 minutes for exactly 3 HOURS post-injection. They cannot leave early. They must not drive home.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Strict routine **BSL**, **HbA1c**, **Lipids**, and **Weight**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Aspiration Check", + "val": "When injecting, you MUST aspirate the syringe for 5-10 seconds before pushing the plunger. If ANY blood appears, you must withdraw and start again. If the pamoate salt hits a vein, it dissolves instantly, hitting the brain with 300mg of Olanzapine at once, causing a PDSS coma.", + "tags": [] + }, + { + "key": "The Gluteal Rule", + "val": "Must ONLY be injected into the gluteal muscle. Deltoid injections are strictly prohibited due to muscle size and vascularity risks.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Olanzapine pamoate salt dissolves extremely slowly in muscle tissue. Broad receptor antagonist (D2, 5-HT2A, H1, M1).", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Peak concentration occurs within 1 week.", + "tags": [] + }, + { + "key": "Half-life", + "val": "30 Days.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ZYPREXA RELPREVV ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Zyprexa Relprevv — A depot formulation of Olanzapine." + }, + { + "label": "Route / Formulation", + "value": "Powder for reconstitution. Forms a thick yellow suspension. (Zyprexa Relprevv)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 150-300 mg every 2 weeks, or 300-405 mg every 4 weeks. Deep gluteal injection ONLY. Max **300 mg** every 2 weeks or **405 mg** every 4 weeks." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia Maintenance: **IM** 150-300 mg every 2 weeks, or 300-405 mg every 4 weeks. Deep gluteal injection ONLY. Initiation: No oral overlap is strictly required if target depot doses are used, though 1-2 days of oral is often given to confirm tolerance." + }, + { + "label": "Best Uses", + "value": "Olanzapine pamoate LAI is a long-acting injectable olanzapine for treatment-resistant schizophrenia, but carries unique post-injection delirium/sedation syndrome (PDSS) requiring 3-hour observation." + }, + { + "label": "Avoid / Cautions", + "value": "Unmonitored administration environments. Severe CNS depression. Acute narrow-angle glaucoma. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Post-Injection Delirium/Sedation Syndrome (PDSS). Presents within 1-3 hours of injection as severe ataxia, delirium, excessive sedation, and coma. Caused by accidental intravascular entry of the suspension. Metabolic: Massive weight gain, new-onset diabetes, extreme hyperlipidemia. Gastrointestinal: Constipation, dry mouth." + }, + { + "label": "Key Interactions", + "value": "Benzodiazepines/Opioids (Additive severe CNS depression). Smoking induces CYP1A2, accelerating olanzapine clearance." + }, + { + "label": "Monitoring", + "value": "The patient MUST remain in the clinic/ward and be physically observed by a nurse every 30 minutes for exactly 3 HOURS post-injection. They cannot leave early. They must not drive home. Strict routine **BSL**, **HbA1c**, **Lipids**, and **Weight**." + }, + { + "label": "Clinical Pearl", + "value": "When injecting, you MUST aspirate the syringe for 5-10 seconds before pushing the plunger. If ANY blood appears, you must withdraw and start again. If the pamoate salt hits a vein, it dissolves instantly, hitting the brain with 300mg of Olanzapine at once, causing a PDSS coma." + } + ] + }, + { + "slug": "paliperidone-lai", + "name": "Paliperidone LAI", + "class": "LAI Antipsychotic", + "subclass": "Invega Depot", + "category": "Psychiatry - Depot Antipsychotics", + "accent": "#0d9488", + "tag": "DEPOT Q1M/Q3M/Q6M", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "150 mg Eq Q4W", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "25–156 Days", + "cls": "", + "flag": "" + }, + { + "label": "Prolactin", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Loading", + "value": "REQUIRED", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The active metabolite of Risperidone formulated as a nanocrystal depot. Extremely convenient as it requires ZERO oral overlap if the specific Day 1 / Day 8 loading protocol is followed.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **150 mg Eq** monthly (Sustenna).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Causes massive and sustained hyperprolactinemia. The loading doses MUST be given in the Deltoid muscle to ensure rapid absorption into the blood.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Paliperidone LAI is a long-acting injectable antipsychotic for schizophrenia maintenance with monthly or 3-monthly dosing, but causes significant hyperprolactinaemia and weight gain.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — Severe hyperprolactinemia (galactorrhea, amenorrhea, gynecomastia, long-term osteoporosis risk).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Extrapyramidal side effects (EPS), particularly at doses > 100 mg Eq.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Weight gain, hyperglycemia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Invega Sustenna (1-Monthly) Loading", + "val": "MANDATORY — Day 1: **IM** 150 mg Eq into the DELTOID. Day 8: **IM** 100 mg Eq into the DELTOID. No oral overlap needed.", + "tags": [] + }, + { + "key": "Invega Sustenna (Maintenance)", + "val": "**IM** 50-150 mg Eq every 4 weeks (Deltoid or Gluteal).", + "tags": [] + }, + { + "key": "Invega Trinza (3-Monthly)", + "val": "**IM** every 12 weeks. ONLY for patients stabilized on Sustenna for at least 4 months.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Invega Sustenna (1-month), Invega Trinza (3-month), Invega Hafyera (6-month)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Pre-filled syringes. Does NOT require refrigeration.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment of Schizophrenia, Schizoaffective disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The most widely prescribed LAI in Australia due to the lack of oral overlap, making it ideal for non-compliant patients discharging from closed wards.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known hypersensitivity to Paliperidone or Risperidone.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "HIGH — Reduce dose significantly if **eGFR** 50-80. Avoid entirely if **eGFR** < 50.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Minimal CYP450 metabolism. Cleared largely unchanged by the kidneys, avoiding major hepatic drug interactions.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive hypotension with antihypertensives (Alpha-1 blockade).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **eGFR** before initiation. Monitor serum Prolactin if sexual dysfunction or lactation occurs. Routine **HbA1c** and **Lipids**.", + "tags": [], + "patient": { + "factors": ["lactation"], + "action": "monitor", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "Check for EPS (tremor/rigidity).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Deltoid Imperative", + "val": "The loading doses on Day 1 and Day 8 MUST go into the Deltoid muscle. Blood flow is much higher in the arm than the glute. If injected into the glute, the drug absorbs too slowly, and the patient will relapse into psychosis during week 2.", + "tags": [] + }, + { + "key": "The Missing Overlap", + "val": "Because there is no oral overlap, if a patient refuses their Day 8 loading dose, their blood levels will crash and the initiation sequence has failed.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Strong D2 and 5-HT2A receptor antagonist. Very low solubility nanocrystals slowly dissolve in the muscle, providing a steady stream of paliperidone into the blood.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. (Deltoid loading ensures therapeutic levels within 48-72 hours).", + "tags": [] + }, + { + "key": "Half-life", + "val": "25-49 Days (Sustenna). Up to 156 Days (Hafyera).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - INVEGA SUSTENNA ARTG/PI/AusPAR and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Invega Depot — The active metabolite of Risperidone formulated as a nanocrystal depot." + }, + { + "label": "Route / Formulation", + "value": "Pre-filled syringes. Does NOT require refrigeration. (Invega Sustenna (1-month), Invega Trinza (3-month), Invega Hafyera (6-month))" + }, + { + "label": "Usual Dose & Max", + "value": "Day 1: **IM** 150 mg Eq into the DELTOID. Day 8: **IM** 100 mg Eq into the DELTOID. No oral overlap needed. Max **150 mg Eq** monthly (Sustenna)." + }, + { + "label": "Key Indication Doses", + "value": "Invega Sustenna (1-Monthly) Loading: Day 1: **IM** 150 mg Eq into the DELTOID. Day 8: **IM** 100 mg Eq into the DELTOID. No oral overlap needed. Invega Sustenna (Maintenance): **IM** 50-150 mg Eq every 4 weeks (Deltoid or Gluteal). Invega Trinza (3-Monthly): **IM** every 12 weeks. ONLY for patients stabilized on Sustenna for at least 4 months." + }, + { + "label": "Best Uses", + "value": "Paliperidone LAI is a long-acting injectable antipsychotic for schizophrenia maintenance with monthly or 3-monthly dosing, but causes significant hyperprolactinaemia and weight gain." + }, + { + "label": "Avoid / Cautions", + "value": "Known hypersensitivity to Paliperidone or Risperidone." + }, + { + "label": "Key Risks", + "value": "Endocrine: Severe hyperprolactinemia (galactorrhea, amenorrhea, gynecomastia, long-term osteoporosis risk). Neurological: Extrapyramidal side effects (EPS), particularly at doses > 100 mg Eq. Metabolic: Weight gain, hyperglycemia." + }, + { + "label": "Key Interactions", + "value": "Minimal CYP450 metabolism. Cleared largely unchanged by the kidneys, avoiding major hepatic drug interactions. Additive hypotension with antihypertensives (Alpha-1 blockade)." + }, + { + "label": "Monitoring", + "value": "Check **eGFR** before initiation. Monitor serum Prolactin if sexual dysfunction or lactation occurs. Routine **HbA1c** and **Lipids**. Check for EPS (tremor/rigidity)." + }, + { + "label": "Clinical Pearl", + "value": "The loading doses on Day 1 and Day 8 MUST go into the Deltoid muscle. Blood flow is much higher in the arm than the glute. If injected into the glute, the drug absorbs too slowly, and the patient will relapse into psychosis during week 2." + } + ] + }, + { + "slug": "risperidone-lai", + "name": "Risperidone LAI", + "class": "LAI Antipsychotic", + "subclass": "Risperdal Consta", + "category": "Psychiatry - Depot Antipsychotics", + "accent": "#0d9488", + "tag": "DEPOT Q2W", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "50 mg Q2W", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3-6 Days", + "cls": "", + "flag": "" + }, + { + "label": "PO Overlap", + "value": "3 WEEKS", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Cold Chain", + "value": "REQUIRED", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The original atypical long-acting injection. Uses a complex microsphere delivery system that creates a massive 3-week delay before the drug actually releases into the blood.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **50 mg** every 2 weeks.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The patient MUST take oral Risperidone every single day for exactly 3 weeks after the first injection. If they do not, they will have zero antipsychotic in their blood.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Risperidone LAI is a fortnightly long-acting injectable for schizophrenia maintenance, but requires 3 weeks of oral supplementation at initiation and causes hyperprolactinaemia.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — Severe hyperprolactinemia.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — EPS, akathisia, somnolence.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Weight gain.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia / Bipolar", + "val": "**IM** 25-50 mg every 2 weeks (Gluteal or Deltoid).", + "tags": [] + }, + { + "key": "Initiation Protocol", + "val": "MANDATORY — Oral Risperidone (e.g., 2-4 mg/day) must be administered concurrently for at least 21 days following the first injection.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Risperdal Consta", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Powder and diluent for reconstitution. MUST be stored in the refrigerator (Cold Chain).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment of Schizophrenia and Bipolar I disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Largely superseded by Paliperidone (Invega) due to the lack of cold-chain requirement and lack of oral overlap, but still used in historically stable patients.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe CNS depression.", + "tags": [] + }, + { + "key": "Elderly & Dementia", + "val": "CAUTION — Increased mortality risk in dementia-related psychosis.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (Fluoxetine, Paroxetine) spike Risperidone levels, worsening EPS/prolactin.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — The most common reason for failure on this drug is the patient failing to take the 3 weeks of oral overlap pills at home.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor Prolactin, **BSL**, and **Lipids**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Cold Chain Crash", + "val": "If the pharmacy leaves Risperdal Consta on the bench overnight, the microspheres degrade. When injected, the entire 2-week dose will dump into the blood instantly on day 1, causing a massive overdose. It must stay in the fridge until 30 mins before use.", + "tags": [] + }, + { + "key": "The Missing Needle", + "val": "The kit contains a highly specific 'SmartSense' needle that prevents needle-stick injuries. If you lose this needle, you cannot use a standard ward needle to inject the thick suspension. The whole kit must be discarded.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Risperidone is encapsulated in polylactide-co-glycolide microspheres. These spheres take 3 weeks to begin biodegrading. Once they break open, they release the drug steadily.", + "tags": [] + }, + { + "key": "Onset", + "val": "Extremely delayed. First main release occurs at 21 days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-6 days (after the microspheres release the drug). Metabolised to Paliperidone via CYP2D6.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - RISPERDAL CONSTA ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Risperdal Consta — The original atypical long-acting injection." + }, + { + "label": "Route / Formulation", + "value": "Powder and diluent for reconstitution. MUST be stored in the refrigerator (Cold Chain). (Risperdal Consta)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 25-50 mg every 2 weeks (Gluteal or Deltoid). Max **50 mg** every 2 weeks." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia / Bipolar: **IM** 25-50 mg every 2 weeks (Gluteal or Deltoid). Initiation Protocol: Oral Risperidone (e.g., 2-4 mg/day) must be administered concurrently for at least 21 days following the first injection." + }, + { + "label": "Best Uses", + "value": "Risperidone LAI is a fortnightly long-acting injectable for schizophrenia maintenance, but requires 3 weeks of oral supplementation at initiation and causes hyperprolactinaemia." + }, + { + "label": "Avoid / Cautions", + "value": "Severe CNS depression." + }, + { + "label": "Key Risks", + "value": "Endocrine: Severe hyperprolactinemia. Neurological: EPS, akathisia, somnolence. Metabolic: Weight gain." + }, + { + "label": "Key Interactions", + "value": "**CYP2D6** inhibitors (Fluoxetine, Paroxetine) spike Risperidone levels, worsening EPS/prolactin." + }, + { + "label": "Monitoring", + "value": "The most common reason for failure on this drug is the patient failing to take the 3 weeks of oral overlap pills at home. Monitor Prolactin, **BSL**, and **Lipids**." + }, + { + "label": "Clinical Pearl", + "value": "If the pharmacy leaves Risperdal Consta on the bench overnight, the microspheres degrade. When injected, the entire 2-week dose will dump into the blood instantly on day 1, causing a massive overdose. It must stay in the fridge until 30 mins before use." + } + ] + }, + { + "slug": "zuclopenthixol-acetate", + "name": "Zuclopenthixol acetate", + "class": "Antipsychotic", + "subclass": "Acuphase (Bridge)", + "category": "Psychiatry - Depot Antipsychotics", + "accent": "#0d9488", + "tag": "72H BRIDGE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg / 4 INJECTIONS", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Duration", + "value": "72 HOURS", + "cls": "good", + "flag": "" + }, + { + "label": "Sedation", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Acute Mania", + "value": "INDICATED", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The 'Bridge' depot. Formulated in a thin oil that lasts exactly 72 hours. Provides immediate, intense sedation and antipsychotic control for acute mania or psychotic emergencies, buying time for oral meds or long-term depots to kick in.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mg per course** (Max 4 injections total).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "NOT a long-term depot. Never prescribe this for maintenance. It is an acute chemical restraint/bridge only.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Zuclopenthixol acetate is a short-acting IM antipsychotic for acute psychosis and severe agitation, but the 72-hour duration means side effects cannot be quickly reversed once administered.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Extreme, unavoidable sedation for 2-3 days. HIGH — EPS, dystonia.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Hypotension, tachycardia.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Dry mouth, constipation.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Psychosis / Mania", + "val": "**IM** 50-150 mg STAT. May repeat in 2-3 days if necessary. Maximum 4 injections (or 400mg total) per acute episode.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Max 25-50 mg STAT. Extremely sensitive.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Clopixol Acuphase", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (50 mg/1 mL). Viscous oil.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital/Psychiatric supply. S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Initial treatment of acute psychoses, mania, or exacerbations of chronic psychoses.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Used in the ED or psychiatric intensive care unit (PICU) when a patient is too violent to take oral meds, and short-acting IM Haloperidol/Droperidol is wearing off too fast.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Maintenance therapy. Parkinson's disease. Severe CNS depression/intoxication.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Zuclopenthixol acetate pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — High-dose Benzodiazepines. Giving Acuphase to a patient already loaded with Midazolam/Diazepam carries a severe risk of respiratory arrest over the next 24 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — The patient will likely sleep for 2 days. You MUST monitor their **SpO2**, **RR**, and ensure they wake up enough to drink water to prevent severe dehydration and VTE risk from immobility.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 3-Day Window", + "val": "Acuphase is the perfect tool for a psychotic patient refusing medications. One injection buys the team exactly 3 days of calm to legally organize treatment orders, establish oral medication regimens, or initiate a 4-weekly depot without fighting the patient every 6 hours for pills.", + "tags": [] + }, + { + "key": "Never Give IV", + "val": "Like all oil-based depots, IV administration will cause fatal pulmonary oil microembolism.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Esterification with acetic acid makes it last 3 days (unlike decanoic acid which lasts 4 weeks). Potent D2, Alpha-1, and H1 blockade.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IM** 2-4 hours. (Peak sedation at 12-24 hours).", + "tags": [] + }, + { + "key": "Duration", + "val": "72 hours (3 Days).", + "tags": [] + }, + { + "key": "Half-life", + "val": "32 hours (Released from the oil matrix).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CLOPIXOL ACUPHASE ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Acuphase (Bridge) — The 'Bridge' depot." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (50 mg/1 mL). Viscous oil. (Clopixol Acuphase)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 50-150 mg STAT. May repeat in 2-3 days if necessary. Maximum 4 injections (or 400mg total) per acute episode. Max **400 mg per course** (Max 4 injections total)." + }, + { + "label": "Key Indication Doses", + "value": "Acute Psychosis / Mania: **IM** 50-150 mg STAT. May repeat in 2-3 days if necessary. Maximum 4 injections (or 400mg total) per acute episode. Elderly / Frail: Max 25-50 mg STAT. Extremely sensitive." + }, + { + "label": "Best Uses", + "value": "Zuclopenthixol acetate is a short-acting IM antipsychotic for acute psychosis and severe agitation, but the 72-hour duration means side effects cannot be quickly reversed once administered." + }, + { + "label": "Avoid / Cautions", + "value": "Maintenance therapy. Parkinson's disease. Severe CNS depression/intoxication. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Extreme, unavoidable sedation for 2-3 days. HIGH — EPS, dystonia. Cardiovascular: Hypotension, tachycardia. Gastrointestinal: Dry mouth, constipation." + }, + { + "label": "Key Interactions", + "value": "High-dose Benzodiazepines. Giving Acuphase to a patient already loaded with Midazolam/Diazepam carries a severe risk of respiratory arrest over the next 24 hours." + }, + { + "label": "Monitoring", + "value": "The patient will likely sleep for 2 days. You MUST monitor their **SpO2**, **RR**, and ensure they wake up enough to drink water to prevent severe dehydration and VTE risk from immobility." + }, + { + "label": "Clinical Pearl", + "value": "Acuphase is the perfect tool for a psychotic patient refusing medications. One injection buys the team exactly 3 days of calm to legally organize treatment orders, establish oral medication regimens, or initiate a 4-weekly depot without fighting the patient every 6 hours for pills." + } + ] + }, + { + "slug": "zuclopenthixol-decanoate", + "name": "Zuclopenthixol decanoate", + "class": "LAI Antipsychotic", + "subclass": "Clopixol Depot", + "category": "Psychiatry - Depot Antipsychotics", + "accent": "#0d9488", + "tag": "DEPOT Q2-4W", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "600 mg/week", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "17 Days", + "cls": "", + "flag": "" + }, + { + "label": "Sedation", + "value": "SEVERE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "EPS Risk", + "value": "HIGH", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "First-Generation Antipsychotic (FGA) depot in fractionated coconut oil. Highly sedating. The ultimate 'calming' depot for chronically violent or severely agitated patients.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **600 mg/week** (Though typical doses are 200-400 mg every 2-4 weeks).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Patients are frequently 'zombified' by this drug. It provides excellent behavioral control but causes profound lethargy and blunting.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Zuclopenthixol decanoate is a depot antipsychotic for maintenance treatment of chronic psychosis, but causes significant extrapyramidal effects and is irreversible once injected (2-4 week duration).", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Severe sedation, apathy, EPS (Parkinsonism, acute dystonia).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Orthostatic hypotension, tachycardia.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Weight gain (less than Olanzapine, but high for an FGA).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia / Severe Agitation", + "val": "**IM** 200-400 mg every 2 to 4 weeks. Deep gluteal Z-Track injection.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Max 50-100 mg every 4 weeks. (Extreme risk of falls/sedation).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Clopixol Depot", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (200 mg/1 mL). Thick oil solution.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment of Schizophrenia and other psychoses, particularly with associated aggression/agitation.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Reserved for the most severely agitated, aggressive, or non-compliant patients who fail modern SGAs.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Parkinson's disease, severe cardiovascular disease, acute severe CNS depression.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Zuclopenthixol decanoate pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Synergistic respiratory depression with high-dose Benzodiazepines or Opioids.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Antihypertensives (Additive hypotension).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for over-sedation and falls, especially in the 3-4 days immediately following the injection.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Baseline **ECG**, **Lipids**, and **Weight**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Calming Anchor", + "val": "While modern psychiatry prefers non-sedating drugs (like Aripiprazole), Zuclopenthixol Depot remains essential in forensic or high-acuity wards where the patient's baseline aggression poses a physical danger to staff and themselves.", + "tags": [] + }, + { + "key": "Viscous Oil", + "val": "Because the suspension is so thick, it must be drawn up with a large-bore needle and injected slowly deep into the glute. Rapid pushing causes severe muscle trauma.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Thioxanthene derivative. Potent D2 antagonist. High affinity for Alpha-1 and H1 receptors (driving the intense sedation and calming effect).", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Steady state takes months.", + "tags": [] + }, + { + "key": "Half-life", + "val": "17 Days (Released slowly from the oil depot).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CLOPIXOL DEPOT ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Clopixol Depot — First-Generation Antipsychotic (FGA) depot in fractionated coconut oil." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (200 mg/1 mL). Thick oil solution. (Clopixol Depot)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 200-400 mg every 2 to 4 weeks. Deep gluteal Z-Track injection. Max **600 mg/week** (Though typical doses are 200-400 mg every 2-4 weeks)." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia / Severe Agitation: **IM** 200-400 mg every 2 to 4 weeks. Deep gluteal Z-Track injection. Elderly / Frail: Max 50-100 mg every 4 weeks. (Extreme risk of falls/sedation)." + }, + { + "label": "Best Uses", + "value": "Zuclopenthixol decanoate is a depot antipsychotic for maintenance treatment of chronic psychosis, but causes significant extrapyramidal effects and is irreversible once injected (2-4 week duration)." + }, + { + "label": "Avoid / Cautions", + "value": "Parkinson's disease, severe cardiovascular disease, acute severe CNS depression. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Severe sedation, apathy, EPS (Parkinsonism, acute dystonia). Cardiovascular: Orthostatic hypotension, tachycardia. Metabolic: Weight gain (less than Olanzapine, but high for an FGA)." + }, + { + "label": "Key Interactions", + "value": "Synergistic respiratory depression with high-dose Benzodiazepines or Opioids. Antihypertensives (Additive hypotension)." + }, + { + "label": "Monitoring", + "value": "Monitor for over-sedation and falls, especially in the 3-4 days immediately following the injection. Baseline **ECG**, **Lipids**, and **Weight**." + }, + { + "label": "Clinical Pearl", + "value": "While modern psychiatry prefers non-sedating drugs (like Aripiprazole), Zuclopenthixol Depot remains essential in forensic or high-acuity wards where the patient's baseline aggression poses a physical danger to staff and themselves." + } + ] + }, + { + "slug": "lithium-carbonate-ir-sr", + "name": "Lithium carbonate (IR/SR)", + "class": "Mood Stabiliser", + "subclass": "Alkali metal cation", + "category": "Psychiatry - Mood Stabilisers", + "accent": "#0891b2", + "tag": "MOOD STAB", + "schedule": "S4", + "stats": [ + { + "label": "Target Range", + "value": "0.6–0.8 mmol/L", + "cls": "accent", + "flag": "accent" + }, + { + "label": "Half-life", + "value": "24 h", + "cls": "", + "flag": "" + }, + { + "label": "Toxicity Risk", + "value": "HIGH", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Renal Adj.", + "value": "MANDATORY", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The absolute gold standard mood stabiliser. Dramatically reduces suicide rates in Bipolar Disorder. Incredibly narrow therapeutic index. Treated like a toxic heavy metal by the kidneys.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated strictly via Therapeutic Drug Monitoring (TDM).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The kidneys cannot tell the difference between Lithium and Sodium. If a patient gets dehydrated (low sodium), the kidney will hoard Lithium, causing fatal toxicity in days.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Lithium carbonate (IR/SR) is the gold-standard mood stabiliser for bipolar disorder with unique anti-suicidal properties, but has an extremely narrow therapeutic index requiring regular serum level, renal, and thyroid monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological (Toxicity)", + "val": "CRITICAL — Coarse tremor, ataxia, confusion, seizures, coma, permanent cerebellar damage (SILENT syndrome).", + "tags": [] + }, + { + "key": "Renal", + "val": "HIGH — Nephrogenic Diabetes Insipidus (polyuria, extreme thirst), chronic interstitial nephritis leading to permanent CKD.", + "tags": [] + }, + { + "key": "Endocrine", + "val": "HIGH — Hypothyroidism (competes with iodine in the thyroid), hyperparathyroidism/hypercalcemia.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea, diarrhea (often early signs of toxicity).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Weight gain.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Bipolar Maintenance", + "val": "Start **PO** 250 mg (IR) **BD** or 450 mg (SR) **OD**. Titrate carefully over weeks. Target blood level: 0.6 - 0.8 mmol/L (Maintenance) or up to 1.0 mmol/L (Acute Mania).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Excreted 100% by the kidneys. Avoid entirely in severe renal failure. If eGFR drops, dose MUST drop.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Quilonum SR (450 mg), Lithicarb (250 mg)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets IR (250 mg). Tablets SR (450 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Bipolar I disorder (mania and maintenance), prevention of recurrent depression.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Unmatched efficacy in true Bipolar disorder. The only psychiatric drug definitively proven to prevent suicide.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal impairment, uncorrected sodium depletion/dehydration.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Causes Ebstein's anomaly (severe fetal cardiac defect).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Lithium carbonate (IR/SR) pregnancy row remains a source-backed high-risk/contraindication prompt." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Triple Whammy (Lithium version)", + "val": "CRITICAL — NSAIDs, ACEi/ARBs, and Thiazide Diuretics. All three of these completely destroy the kidney's ability to excrete Lithium, doubling blood levels and causing lethal toxicity. DO NOT prescribe Ibuprofen, Perindopril, or HCTZ to a Lithium patient.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **TDM** (Serum Lithium Level) checked strictly 12 HOURS post-dose. Must wait 5-7 days after a dose change to check. Target 0.6-0.8 mmol/L.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — 6-monthly **U&E**, **eGFR**, **TFTs**, and Calcium levels for life.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — 'Sick Day Rules': If the patient gets gastro/vomiting, they must stop Lithium immediately and go to hospital. Dehydration = Toxicity.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The NSAID Death Trap", + "val": "A patient on stable Lithium takes Nurofen (Ibuprofen) for a sprained ankle for 3 days. The NSAID restricts renal blood flow. The Lithium spikes to 2.5 mmol/L. The patient seizes and dies. Always check the medication list.", + "tags": [] + }, + { + "key": "Fine vs Coarse", + "val": "A *fine* tremor of the hands is a normal side effect of Lithium. A *coarse* tremor (flapping, unable to hold a cup of coffee) is a red-flag medical emergency indicating severe neuro-toxicity.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Exact mechanism unknown. Alters cation transport across cell membranes in nerve/muscle cells. Influences serotonin/norepinephrine reuptake and inhibits second-messenger systems (inositol monophosphatase).", + "tags": [] + }, + { + "key": "Onset", + "val": "1-3 weeks for antimanic effect.", + "tags": [] + }, + { + "key": "Half-life", + "val": "24 hours (Takes 5-7 days to reach steady state in the blood!).", + "tags": [] + } + ] + }, + { + "title": "Special Populations", + "type": "spec", + "rows": [ + { + "key": "Elderly / Frail", + "val": "MANDATORY — Start at 150-300 mg **OD**. Elderly kidneys clear Lithium 30-50% more slowly; standard doses cause toxicity. Target serum levels 0.4-0.6 mmol/L (lower than young adults). Monitor **U&E** and **Lithium** levels fortnightly until stable.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Lithium is 100% renally excreted. Any decline in **eGFR** causes rapid toxic accumulation. Halve the dose if **eGFR** drops below 45. Avoid if **eGFR** < 15. Do NOT use NSAIDs concurrently.", + "tags": [], + "patient": { + "factors": ["renal", "allergy-nsaid"], + "action": "dose-adjust", + "severity": "danger", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CRITICAL — **Pregnancy** Category D. Ebstein's anomaly risk (tricuspid valve malformation) in first trimester. If essential, requires specialist perinatal liaison. Lithium levels change dramatically with the volume expansion of pregnancy — monitor weekly.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Lactation", + "val": "CAUTION — Lithium passes into breast milk at 10-50% of maternal serum level. Infant serum monitoring required. Consider weaning if levels cannot be kept low.", + "tags": [], + "patient": { + "factors": ["lactation", "paediatric"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - LITHICARB ARTG/PI and PBS search checked 2026-05-10 for mood-stabiliser/anticonvulsant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alkali metal cation — The absolute gold standard mood stabiliser." + }, + { + "label": "Route / Formulation", + "value": "Tablets IR (250 mg). Tablets SR (450 mg). (Quilonum SR (450 mg), Lithicarb (250 mg))" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 250 mg (IR) **BD** or 450 mg (SR) **OD**. Titrate carefully over weeks. Target blood level: 0.6 - 0.8 mmol/L (Maintenance) or up to 1.0 mmol/L (Acute Mania). Titrated strictly via Therapeutic Drug Monitoring (TDM)." + }, + { + "label": "Key Indication Doses", + "value": "Bipolar Maintenance: Start **PO** 250 mg (IR) **BD** or 450 mg (SR) **OD**. Titrate carefully over weeks. Target blood level: 0.6 - 0.8 mmol/L (Maintenance) or up to 1.0 mmol/L (Acute Mania). Renal Impairment: Excreted 100% by the kidneys. Avoid entirely in severe renal failure. If eGFR drops, dose MUST drop." + }, + { + "label": "Best Uses", + "value": "Lithium carbonate (IR/SR) is the gold-standard mood stabiliser for bipolar disorder with unique anti-suicidal properties, but has an extremely narrow therapeutic index requiring regular serum level, renal, and thyroid monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal impairment, uncorrected sodium depletion/dehydration. **Pregnancy** Category D. Causes Ebstein's anomaly (severe fetal cardiac defect)." + }, + { + "label": "Key Risks", + "value": "Neurological (Toxicity): Coarse tremor, ataxia, confusion, seizures, coma, permanent cerebellar damage (SILENT syndrome). Renal: Nephrogenic Diabetes Insipidus (polyuria, extreme thirst), chronic interstitial nephritis leading to permanent CKD. Endocrine: Hypothyroidism (competes with iodine in the thyroid), hyperparathyroidism/hypercalcemia. Gastrointestinal: Nausea, diarrhea (often early signs of toxicity)." + }, + { + "label": "Key Interactions", + "value": "NSAIDs, ACEi/ARBs, and Thiazide Diuretics. All three of these completely destroy the kidney's ability to excrete Lithium, doubling blood levels and causing lethal toxicity. DO NOT prescribe Ibuprofen, Perindopril, or HCTZ to a Lithium patient." + }, + { + "label": "Monitoring", + "value": "**TDM** (Serum Lithium Level) checked strictly 12 HOURS post-dose. Must wait 5-7 days after a dose change to check. Target 0.6-0.8 mmol/L. 6-monthly **U&E**, **eGFR**, **TFTs**, and Calcium levels for life. 'Sick Day Rules': If the patient gets gastro/vomiting, they must stop Lithium immediately and go to hospital. Dehydration = Toxicity." + }, + { + "label": "Clinical Pearl", + "value": "A patient on stable Lithium takes Nurofen (Ibuprofen) for a sprained ankle for 3 days. The NSAID restricts renal blood flow. The Lithium spikes to 2.5 mmol/L. The patient seizes and dies. Always check the medication list." + } + ] + }, + { + "slug": "oxcarbazepine", + "name": "Oxcarbazepine", + "class": "Mood Stabiliser", + "subclass": "10-keto analogue of CBZ", + "category": "Psychiatry - Mood Stabilisers", + "accent": "#0891b2", + "tag": "MOOD STAB", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "2400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "9 h (MHD)", + "cls": "", + "flag": "" + }, + { + "label": "Hyponatremia", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "CYP Inducer", + "value": "MILD", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Structural analogue of Carbamazepine. Designed to bypass the toxic liver-enzyme induction of its predecessor. Has far fewer drug interactions but carries a massively higher risk of severe hyponatremia.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2400 mg/day** (given in divided doses).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Up to 30% of patients develop low sodium (SIADH-like effect). Elderly patients are at extreme risk of hyponatremic seizures and coma.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Oxcarbazepine is an anticonvulsant related to carbamazepine with fewer drug interactions, but causes clinically significant hyponatraemia more frequently and still requires monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "CRITICAL — Severe hyponatremia (<125 mmol/L). Often asymptomatic until the patient suddenly seizes or becomes comatose.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "HIGH — SJS/TEN and DRESS syndrome (High risk in patients with HLA-B*1502 allele, common in Asian populations). Cross-reacts in 30% of patients with a Carbamazepine allergy.", + "tags": [] + }, + { + "key": "Neurological", + "val": "MODERATE — Dizziness, somnolence, diplopia (double vision).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Epilepsy / Bipolar Maintenance", + "val": "Start **PO** 300 mg **BD**. Titrate up by 600 mg/day every week. Target 900-2400 mg/day.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Halve the starting dose (150 mg BD) if **eGFR** < 30.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Trileptal", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (150, 300, 600 mg). Oral suspension.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Focal (partial) seizures.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Bipolar disorder (maintenance), Trigeminal neuralgia.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "A cleaner, safer alternative to Carbamazepine for focal epilepsy or bipolar disorder, provided the patient's sodium levels remain stable.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known hypersensitivity to carbamazepine (extreme caution).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category D. Teratogenic (craniofacial defects, heart defects).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Oxcarbazepine pregnancy row remains a source-backed high-risk/contraindication prompt." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — Weak inducer of CYP3A4, but strong enough to completely destroy the efficacy of oral contraceptives (OCPs), causing unplanned pregnancy. Must use IUD or barrier.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Inhibits CYP2C19. Will significantly raise blood levels of Phenytoin.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **U&E** (sodium) at baseline, 2 weeks, 1 month, 3 months, and if the patient develops lethargy or confusion.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Instruct the patient to immediately report any skin rash or mucosal blistering (SJS).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Carbamazepine Upgrade", + "val": "Carbamazepine is a metabolic nightmare because it induces its own metabolism (auto-induction) and destroys the blood levels of almost every other drug the patient takes. Oxcarbazepine does not auto-induce, making blood levels highly stable and polypharmacy much safer.", + "tags": [] + }, + { + "key": "The Water Intoxication", + "val": "The hyponatremia is caused by the drug increasing the kidney's sensitivity to ADH (Antidiuretic Hormone). The patient retains free water, diluting their sodium. Fluid restriction is the first-line treatment if sodium drops.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Prodrug. Rapidly reduced in the liver to the active metabolite (Monohydroxy Derivative, MHD). Blocks voltage-gated sodium channels, stabilizing hyperexcited neural membranes.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Parent drug: 2 hours. Active MHD: 9 hours. (Must be dosed BD).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - TRILEPTAL ARTG/PI and PBS search checked 2026-05-10 for mood-stabiliser/anticonvulsant batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "10-keto analogue of CBZ — Structural analogue of Carbamazepine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (150, 300, 600 mg). Oral suspension. (Trileptal)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 300 mg **BD**. Titrate up by 600 mg/day every week. Target 900-2400 mg/day. Max **2400 mg/day** (given in divided doses)." + }, + { + "label": "Key Indication Doses", + "value": "Epilepsy / Bipolar Maintenance: Start **PO** 300 mg **BD**. Titrate up by 600 mg/day every week. Target 900-2400 mg/day. Renal Impairment: Halve the starting dose (150 mg BD) if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Oxcarbazepine is an anticonvulsant related to carbamazepine with fewer drug interactions, but causes clinically significant hyponatraemia more frequently and still requires monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Known hypersensitivity to carbamazepine (extreme caution). **Pregnancy** Category D. Teratogenic (craniofacial defects, heart defects)." + }, + { + "label": "Key Risks", + "value": "Metabolic: Severe hyponatremia (<125 mmol/L). Often asymptomatic until the patient suddenly seizes or becomes comatose. Dermatological: SJS/TEN and DRESS syndrome (High risk in patients with HLA-B*1502 allele, common in Asian populations). Cross-reacts in 30% of patients with a Carbamazepine allergy. Neurological: Dizziness, somnolence, diplopia (double vision)." + }, + { + "label": "Key Interactions", + "value": "Weak inducer of CYP3A4, but strong enough to completely destroy the efficacy of oral contraceptives (OCPs), causing unplanned pregnancy. Must use IUD or barrier. Inhibits CYP2C19. Will significantly raise blood levels of Phenytoin." + }, + { + "label": "Monitoring", + "value": "Check **U&E** (sodium) at baseline, 2 weeks, 1 month, 3 months, and if the patient develops lethargy or confusion. Instruct the patient to immediately report any skin rash or mucosal blistering (SJS)." + }, + { + "label": "Clinical Pearl", + "value": "Carbamazepine is a metabolic nightmare because it induces its own metabolism (auto-induction) and destroys the blood levels of almost every other drug the patient takes. Oxcarbazepine does not auto-induce, making blood levels highly stable and polypharmacy much safer." + } + ] + }, + { + "slug": "amisulpride", + "name": "Amisulpride", + "class": "Antipsychotic", + "subclass": "SGA / Selective D2/D3", + "category": "Psychiatry - Oral Antipsychotics", + "accent": "#059669", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1200 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "12 h", + "cls": "", + "flag": "" + }, + { + "label": "Prolactin", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly selective D2/D3 antagonist. Acts differently depending on the dose (low doses for negative symptoms, high doses for psychosis). Very low metabolic risk but causes profound hyperprolactinemia.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1200 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Unlike most antipsychotics which are cleared by the liver, Amisulpride is cleared almost entirely by the kidneys. Unadjusted doses in CKD cause severe toxicity.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Amisulpride is a selective D2/D3 antagonist effective for both positive and negative symptoms of schizophrenia, but causes significant hyperprolactinaemia and requires renal dose adjustment.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — Severe hyperprolactinemia (galactorrhea, amenorrhea, sexual dysfunction). The highest risk of all SGAs alongside Risperidone/Paliperidone.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — EPS, akathisia, tremor (dose-dependent > 400mg).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — **QTc** prolongation, bradycardia.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Psychosis (Positive Symptoms)", + "val": "**PO** 400-800 mg/day in divided doses. Max 1200 mg/day.", + "tags": [] + }, + { + "key": "Predominantly Negative Symptoms", + "val": "**PO** 50-300 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** 30-60, halve the dose. If **eGFR** 10-30, reduce dose to one-third. If **eGFR** < 10, avoid.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Solian", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (100, 200, 400 mg). Oral liquid (100 mg/mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia (both acute exacerbations and maintenance).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly effective. Often ranked second only to Clozapine in efficacy for schizophrenia. Excellent for patients with prominent negative symptoms (apathy, anhedonia).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Prolactin-dependent tumors (e.g., pituitary prolactinoma, certain breast cancers), pheochromocytoma, severe renal failure.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Amisulpride pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Concurrent use of Levodopa (directly antagonizes Parkinson's therapy).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — QTc prolonging agents (Amiodarone, SSRIs).", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "SAFE — Zero significant CYP450 interactions (Safe to mix with liver-metabolized drugs).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — **eGFR** must be checked prior to initiation. Monitor serum Prolactin if symptoms develop.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Baseline **ECG** (QTc monitoring).", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Clean Profile", + "val": "Because it ignores histamine, muscarinic, and alpha receptors, Amisulpride does not cause sleepiness, dry mouth, or massive blood pressure drops. Patients feel 'clear-headed' compared to Olanzapine or Quetiapine.", + "tags": [] + }, + { + "key": "The Low-Dose Trick", + "val": "In a patient suffering from purely negative symptoms of schizophrenia (lying in bed, no motivation, flat affect), giving a massive 800mg dose will make them worse. A tiny 50-100mg dose triggers presynaptic dopamine release, acting like a stimulant to wake them up.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Pure D2 and D3 receptor antagonist. Has zero affinity for serotonin, histamine, or muscarinic receptors (hence zero sedation or dry mouth). At low doses, it blocks presynaptic autoreceptors, *increasing* dopamine release (treating negative symptoms). At high doses, it blocks postsynaptic receptors (treating psychosis).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-3 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "12 hours. Cleared largely unchanged in the urine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - SOLIAN ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Selective D2/D3 — Highly selective D2/D3 antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (100, 200, 400 mg). Oral liquid (100 mg/mL). (Solian)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 400-800 mg/day in divided doses. Max 1200 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Acute Psychosis (Positive Symptoms): **PO** 400-800 mg/day in divided doses. Max 1200 mg/day. Predominantly Negative Symptoms: **PO** 50-300 mg **OD**. Renal Impairment: If **eGFR** 30-60, halve the dose. If **eGFR** 10-30, reduce dose to one-third. If **eGFR** < 10, avoid." + }, + { + "label": "Best Uses", + "value": "Amisulpride is a selective D2/D3 antagonist effective for both positive and negative symptoms of schizophrenia, but causes significant hyperprolactinaemia and requires renal dose adjustment." + }, + { + "label": "Avoid / Cautions", + "value": "Prolactin-dependent tumors (e.g., pituitary prolactinoma, certain breast cancers), pheochromocytoma, severe renal failure. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Endocrine: Severe hyperprolactinemia (galactorrhea, amenorrhea, sexual dysfunction). The highest risk of all SGAs alongside Risperidone/Paliperidone. Neurological: EPS, akathisia, tremor (dose-dependent > 400mg). Cardiovascular: **QTc** prolongation, bradycardia." + }, + { + "label": "Key Interactions", + "value": "Concurrent use of Levodopa (directly antagonizes Parkinson's therapy). QTc prolonging agents (Amiodarone, SSRIs). Zero significant CYP450 interactions (Safe to mix with liver-metabolized drugs)." + }, + { + "label": "Monitoring", + "value": "**eGFR** must be checked prior to initiation. Monitor serum Prolactin if symptoms develop. Baseline **ECG** (QTc monitoring)." + }, + { + "label": "Clinical Pearl", + "value": "Because it ignores histamine, muscarinic, and alpha receptors, Amisulpride does not cause sleepiness, dry mouth, or massive blood pressure drops. Patients feel 'clear-headed' compared to Olanzapine or Quetiapine." + } + ] + }, + { + "slug": "asenapine", + "name": "Asenapine", + "class": "Antipsychotic", + "subclass": "SGA / Sublingual", + "category": "Psychiatry - Oral Antipsychotics", + "accent": "#059669", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "24 h", + "cls": "", + "flag": "" + }, + { + "label": "Route", + "value": "SUBLINGUAL ONLY", + "cls": "purple", + "flag": "warn" + }, + { + "label": "Fasting", + "value": "10 MINS POST DOSE", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Sublingual-only SGA. Highly effective for acute mania. Cannot be swallowed due to total destruction by liver first-pass metabolism.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day** (10 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The patient must NOT eat or drink for 10 minutes after the wafer dissolves, or the drug will wash into the stomach and be rendered useless.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Asenapine is a sublingual atypical antipsychotic for schizophrenia and bipolar mania, but must be dissolved sublingually (not swallowed) and causes oral hypoaesthesia and taste disturbance.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Somnolence, sedation, akathisia, EPS.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Oral hypoesthesia (numbness of the tongue/mouth), dysgeusia (bad taste).", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Weight gain (less than Olanzapine, more than Aripiprazole).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Bipolar Mania / Schizophrenia", + "val": "**SL** 5-10 mg **BD**. Place under tongue and allow to dissolve completely.", + "tags": [] + }, + { + "key": "Administration Rule", + "val": "MANDATORY — Do not chew, crush, or swallow. Nil By Mouth for 10 minutes post-dose.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Saphris", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Sublingual Wafers (5 mg, 10 mg). Black cherry flavor.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Bipolar I disorder (acute mania/mixed episodes), Schizophrenia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Rapid acting for acute mania. Good alternative if patients struggle with swallowing tablets or require rapid absorption without an injection.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe hepatic impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Asenapine pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP1A2** inhibitors (Fluvoxamine, Ciprofloxacin) significantly increase asenapine levels.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive sedation with CNS depressants and hypotension with antihypertensives.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Supervise administration. Psychiatric patients frequently swallow the wafer or immediately drink water to wash the bad taste away, which guarantees the drug will fail. They must hold it under the tongue.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Baseline **BSL** and **Lipids**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Numb Tongue", + "val": "Warn the patient that their tongue will feel numb or tingle after the wafer dissolves. This is a local anesthetic-like effect of the drug molecule itself, not an allergic reaction. It fades in 30 minutes.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Broad multi-receptor antagonist (D2, 5-HT2A, H1, Alpha-1).", + "tags": [] + }, + { + "key": "Onset", + "val": "**SL** 30-60 mins (Absorbed directly through the oral mucosa into the systemic circulation).", + "tags": [] + }, + { + "key": "Half-life", + "val": "24 hours. If swallowed, bioavailability drops from 35% to < 2% due to massive CYP1A2 hepatic clearance.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - SAPHRIS ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Sublingual — Sublingual-only SGA." + }, + { + "label": "Route / Formulation", + "value": "Sublingual Wafers (5 mg, 10 mg). Black cherry flavor. (Saphris)" + }, + { + "label": "Usual Dose & Max", + "value": "**SL** 5-10 mg **BD**. Place under tongue and allow to dissolve completely. Max **20 mg/day** (10 mg BD)." + }, + { + "label": "Key Indication Doses", + "value": "Bipolar Mania / Schizophrenia: **SL** 5-10 mg **BD**. Place under tongue and allow to dissolve completely. Administration Rule: Do not chew, crush, or swallow. Nil By Mouth for 10 minutes post-dose." + }, + { + "label": "Best Uses", + "value": "Asenapine is a sublingual atypical antipsychotic for schizophrenia and bipolar mania, but must be dissolved sublingually (not swallowed) and causes oral hypoaesthesia and taste disturbance." + }, + { + "label": "Avoid / Cautions", + "value": "Severe hepatic impairment. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Somnolence, sedation, akathisia, EPS. Gastrointestinal: Oral hypoesthesia (numbness of the tongue/mouth), dysgeusia (bad taste). Metabolic: Weight gain (less than Olanzapine, more than Aripiprazole)." + }, + { + "label": "Key Interactions", + "value": "**CYP1A2** inhibitors (Fluvoxamine, Ciprofloxacin) significantly increase asenapine levels. Additive sedation with CNS depressants and hypotension with antihypertensives." + }, + { + "label": "Monitoring", + "value": "Supervise administration. Psychiatric patients frequently swallow the wafer or immediately drink water to wash the bad taste away, which guarantees the drug will fail. They must hold it under the tongue. Baseline **BSL** and **Lipids**." + }, + { + "label": "Clinical Pearl", + "value": "Warn the patient that their tongue will feel numb or tingle after the wafer dissolves. This is a local anesthetic-like effect of the drug molecule itself, not an allergic reaction. It fades in 30 minutes." + } + ] + }, + { + "slug": "brexpiprazole", + "name": "Brexpiprazole", + "class": "Antipsychotic", + "subclass": "SGA / Partial D2", + "category": "Psychiatry - Oral Antipsychotics", + "accent": "#059669", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "4 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "91 h", + "cls": "", + "flag": "" + }, + { + "label": "Akathisia", + "value": "LOWER THAN ARI", + "cls": "good", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Next-generation partial dopamine agonist (structurally similar to Aripiprazole). Designed to provide the same metabolic safety as Aripiprazole but with vastly reduced rates of agonizing akathisia.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4 mg/day** (Schizophrenia) or **3 mg/day** (MDD adjunct).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Exceptionally long half-life. Takes nearly 2 weeks to reach steady state.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Brexpiprazole is a next-generation partial dopamine agonist with less akathisia than aripiprazole, but has limited clinical differentiation and is more expensive.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "MODERATE — Akathisia (9%, compared to ~25% for Aripiprazole), headache, tremor.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Weight gain (slightly more than Aripiprazole, but much less than Olanzapine/Quetiapine).", + "tags": [] + }, + { + "key": "Endocrine", + "val": "SAFE — Does not raise prolactin.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia", + "val": "Start **PO** 1 mg **OD**. Titrate up over 1-2 weeks. Target 2-4 mg **OD**.", + "tags": [] + }, + { + "key": "MDD Adjunct", + "val": "Start **PO** 0.5-1 mg **OD**. Max 3 mg/day.", + "tags": [] + }, + { + "key": "Renal / Hepatic Impairment", + "val": "MANDATORY — Max 3 mg/day if **eGFR** < 60 or in moderate/severe hepatic impairment.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Rexulti", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (0.25, 0.5, 1, 2, 3, 4 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Adjunctive treatment of Major Depressive Disorder.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Often the direct switch target for a patient who responds beautifully to Aripiprazole but cannot tolerate the severe restlessness (akathisia).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known hypersensitivity.", + "tags": [] + }, + { + "key": "Elderly & Dementia", + "val": "CAUTION — Black Box Warning for increased mortality in dementia-related psychosis.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Brexpiprazole pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong **CYP2D6** inhibitors (Fluoxetine, Paroxetine) or **CYP3A4** inhibitors (Clarithromycin) require the Brexpiprazole dose to be halved. If on BOTH, dose must be quartered.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Baseline **BSL**, **Lipids**, and **Weight**.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Monitor for akathisia (pacing, rocking, inability to sit still), though risk is mitigated.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 'Aripiprazole Lite' Paradigm", + "val": "Because Brexpiprazole binds to the D2 receptor but activates it less strongly than Aripiprazole, it is less 'stimulating'. It sits perfectly in the goldilocks zone between the heavy sedation of Quetiapine and the intense activation of Aripiprazole.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Partial agonist at D2 and 5-HT1A receptors, but with *lower* intrinsic dopamine activity than Aripiprazole (acts more like a pure antagonist), resulting in less motor activation. Potent antagonist at 5-HT2A.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "91 hours. Metabolised by CYP3A4 and CYP2D6.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - REXULTI ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Partial D2 — Next-generation partial dopamine agonist (structurally similar to Aripiprazole)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (0.25, 0.5, 1, 2, 3, 4 mg). (Rexulti)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 1 mg **OD**. Titrate up over 1-2 weeks. Target 2-4 mg **OD**. Max **4 mg/day** (Schizophrenia) or **3 mg/day** (MDD adjunct)." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia: Start **PO** 1 mg **OD**. Titrate up over 1-2 weeks. Target 2-4 mg **OD**. MDD Adjunct: Start **PO** 0.5-1 mg **OD**. Max 3 mg/day. Renal / Hepatic Impairment: Max 3 mg/day if **eGFR** < 60 or in moderate/severe hepatic impairment." + }, + { + "label": "Best Uses", + "value": "Brexpiprazole is a next-generation partial dopamine agonist with less akathisia than aripiprazole, but has limited clinical differentiation and is more expensive." + }, + { + "label": "Avoid / Cautions", + "value": "Known hypersensitivity. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Akathisia (9%, compared to ~25% for Aripiprazole), headache, tremor. Metabolic: Weight gain (slightly more than Aripiprazole, but much less than Olanzapine/Quetiapine). Endocrine: Does not raise prolactin." + }, + { + "label": "Key Interactions", + "value": "Strong **CYP2D6** inhibitors (Fluoxetine, Paroxetine) or **CYP3A4** inhibitors (Clarithromycin) require the Brexpiprazole dose to be halved. If on BOTH, dose must be quartered." + }, + { + "label": "Monitoring", + "value": "Baseline **BSL**, **Lipids**, and **Weight**. Monitor for akathisia (pacing, rocking, inability to sit still), though risk is mitigated." + }, + { + "label": "Clinical Pearl", + "value": "Because Brexpiprazole binds to the D2 receptor but activates it less strongly than Aripiprazole, it is less 'stimulating'. It sits perfectly in the goldilocks zone between the heavy sedation of Quetiapine and the intense activation of Aripiprazole." + } + ] + }, + { + "slug": "cariprazine", + "name": "Cariprazine", + "class": "Antipsychotic", + "subclass": "SGA / Partial D2/D3", + "category": "Psychiatry - Oral Antipsychotics", + "accent": "#059669", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "6 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1-3 WEEKS", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Akathisia", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "D3 Affinity", + "value": "UNIQUE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Unique partial agonist with a massive affinity for the Dopamine D3 receptor over the D2 receptor. Targets negative and cognitive symptoms of schizophrenia. Exceptionally long half-life.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **6 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Active metabolites last up to 3 weeks in the blood. Side effects (like severe akathisia) can appear weeks after a dose change, and persist for weeks after the drug is ceased.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Cariprazine is a partial D3-preferring dopamine agonist effective for bipolar depression and schizophrenia negative symptoms, but has a very long effective half-life (2-3 weeks) due to active metabolites.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Severe Akathisia (up to 20% incidence, often delayed onset). HIGH — Extrapyramidal symptoms (EPS), insomnia.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "SAFE — Generally weight-neutral and lipid-neutral.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Minimal effect on QTc or BP.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia", + "val": "Start **PO** 1.5 mg **OD**. Titrate slowly (e.g., every 1-2 weeks) to 3-6 mg/day.", + "tags": [] + }, + { + "key": "Bipolar Mania", + "val": "Start **PO** 1.5 mg **OD**. Titrate to 3-6 mg/day.", + "tags": [] + }, + { + "key": "Renal / Hepatic", + "val": "MANDATORY — Avoid if severe renal (**eGFR** < 30) or severe hepatic impairment.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Reagila", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (1.5 mg, 3 mg, 4.5 mg, 6 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia in adults.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly valued for patients struggling with negative symptoms (apathy, anhedonia, poor motivation) due to its unique D3 receptor action.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent use of strong CYP3A4 inhibitors or inducers.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category D (Based on animal toxicity data).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Cariprazine pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Strong **CYP3A4** inhibitors (Clarithromycin, Ketoconazole) require the Cariprazine dose to be halved. CYP3A4 inducers (Carbamazepine) will completely destroy blood levels; avoid combination.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor closely for akathisia. Because of the 3-week half-life, you must wait 2-3 weeks between dose increases to accurately assess the patient's true steady-state tolerance.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Routine **BSL** and **Weight**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The D3 Difference", + "val": "Standard antipsychotics block D2 to stop hallucinations, but this worsens apathy and motivation. Cariprazine's unique D3 partial-agonism gently stimulates the brain's reward centers, waking the patient up and restoring emotional drive.", + "tags": [] + }, + { + "key": "The Ghost Side-Effect", + "val": "If a patient develops severe akathisia and you stop the Cariprazine, the akathisia will NOT go away the next day. The active metabolite will remain in their brain for another 3 weeks. You must prescribe Propranolol or Benztropine to bridge them until it washes out.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Partial agonist at D3 and D2 receptors, with a 10-fold higher affinity for D3. D3 receptors are heavily localized in the ventral striatum (reward, motivation, and emotion pathways).", + "tags": [] + }, + { + "key": "Onset", + "val": "Weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Parent drug: 2-4 days. Major active metabolite (DDCAR): 1-3 WEEKS. CYP3A4 metabolism.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - REAGILA ARTG/PI/AusPMDS and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Partial D2/D3 — Unique partial agonist with a massive affinity for the Dopamine D3 receptor over the D2 receptor." + }, + { + "label": "Route / Formulation", + "value": "Capsules (1.5 mg, 3 mg, 4.5 mg, 6 mg). (Reagila)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 1.5 mg **OD**. Titrate slowly (e.g., every 1-2 weeks) to 3-6 mg/day. Max **6 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia: Start **PO** 1.5 mg **OD**. Titrate slowly (e.g., every 1-2 weeks) to 3-6 mg/day. Bipolar Mania: Start **PO** 1.5 mg **OD**. Titrate to 3-6 mg/day. Renal / Hepatic: Avoid if severe renal (**eGFR** < 30) or severe hepatic impairment." + }, + { + "label": "Best Uses", + "value": "Cariprazine is a partial D3-preferring dopamine agonist effective for bipolar depression and schizophrenia negative symptoms, but has a very long effective half-life (2-3 weeks) due to active metabolites." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of strong CYP3A4 inhibitors or inducers. **Pregnancy** Category D (Based on animal toxicity data)." + }, + { + "label": "Key Risks", + "value": "Neurological: Severe Akathisia (up to 20% incidence, often delayed onset). HIGH — Extrapyramidal symptoms (EPS), insomnia. Metabolic: Generally weight-neutral and lipid-neutral. Cardiovascular: Minimal effect on QTc or BP." + }, + { + "label": "Key Interactions", + "value": "Strong **CYP3A4** inhibitors (Clarithromycin, Ketoconazole) require the Cariprazine dose to be halved. CYP3A4 inducers (Carbamazepine) will completely destroy blood levels; avoid combination." + }, + { + "label": "Monitoring", + "value": "Monitor closely for akathisia. Because of the 3-week half-life, you must wait 2-3 weeks between dose increases to accurately assess the patient's true steady-state tolerance. Routine **BSL** and **Weight**." + }, + { + "label": "Clinical Pearl", + "value": "Standard antipsychotics block D2 to stop hallucinations, but this worsens apathy and motivation. Cariprazine's unique D3 partial-agonism gently stimulates the brain's reward centers, waking the patient up and restoring emotional drive." + } + ] + }, + { + "slug": "chlorpromazine", + "name": "Chlorpromazine", + "class": "Antipsychotic", + "subclass": "FGA / Phenothiazine", + "category": "Psychiatry - Oral Antipsychotics", + "accent": "#2563eb", + "tag": "FGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1000 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "30 h", + "cls": "", + "flag": "" + }, + { + "label": "Sedation", + "value": "SEVERE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Orthostasis", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The first antipsychotic ever discovered (1952). Low-potency FGA. Exceptionally sedating and highly anticholinergic. Rarely used for primary psychosis today, but heavily utilized in palliative care and for intractable hiccups.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1000 mg/day** (Modern doses rarely exceed 100-300 mg).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Causes profound orthostatic hypotension. The patient will collapse if they stand up quickly after a large dose.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Chlorpromazine is the original first-generation antipsychotic still used for refractory psychosis and intractable hiccups, but causes severe sedation, photosensitivity, and significant anticholinergic and extrapyramidal effects.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Severe orthostatic hypotension, reflex tachycardia, **QTc** prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "HIGH — Profound sedation, hangover, EPS, lowers seizure threshold. Neuroleptic Malignant Syndrome (NMS).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe anticholinergic toxidrome (constipation, urinary retention, dry mouth).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "MODERATE — Photosensitivity, blue-grey skin pigmentation (with chronic high-dose use).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Psychosis / Agitation", + "val": "**PO** 25-100 mg **TDS** to **QID**.", + "tags": [] + }, + { + "key": "Intractable Hiccups", + "val": "**PO** 25-50 mg **TDS**.", + "tags": [] + }, + { + "key": "Palliative Agitation / Nausea", + "val": "**PO** or **IV** 12.5 - 25 mg q4-8h PRN.", + "tags": [] + }, + { + "key": "Elderly", + "val": "MANDATORY — Start at 10-25 mg/day. High risk of falls and delirium.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Largactil", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10, 25, 100 mg). Oral syrup (5 mg/mL).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (50 mg/2 mL) for **IM** or **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia, acute mania, severe behavioral disturbance, intractable hiccups, severe nausea in terminal illness.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Relegated to a rescue sedative or palliative antiemetic. The heavy side effect burden makes it obsolete for chronic maintenance therapy.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe CNS depression, coma, bone marrow depression, narrow-angle glaucoma.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Chlorpromazine pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive hypotension with BP meds. Additive severe CNS depression with Opioids/Benzos.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive anticholinergic toxicity with TCAs or Oxybutynin (can trigger toxic megacolon).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Check lying/standing **BP**. Restrict patient to bed rest for 1-2 hours after an acute large dose to prevent syncopal falls.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Baseline **ECG**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Hiccup Hack", + "val": "Chlorpromazine is the only FDA/TGA approved drug for intractable hiccups (lasting > 48 hours). It suppresses the medullary reflex arc that drives the diaphragm spasms.", + "tags": [] + }, + { + "key": "The Chemical Restraint", + "val": "In a severely violent, psychotic patient where Haloperidol has failed, 100mg of Chlorpromazine provides the ultimate 'chemical blanket', heavily sedating the patient via four different receptor pathways simultaneously.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Low-affinity D2 receptor antagonist (antipsychotic). Very high affinity antagonist at Histamine H1 (massive sedation), Alpha-1 (massive hypotension), and Muscarinic M1 (dry mouth/constipation) receptors.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "30 hours. Extensively metabolised in the liver to dozens of active/inactive metabolites.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - LARGACTIL ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "FGA / Phenothiazine — The first antipsychotic ever discovered (1952)." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10, 25, 100 mg). Oral syrup (5 mg/mL). (Largactil)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 25-100 mg **TDS** to **QID**. Max **1000 mg/day** (Modern doses rarely exceed 100-300 mg)." + }, + { + "label": "Key Indication Doses", + "value": "Acute Psychosis / Agitation: **PO** 25-100 mg **TDS** to **QID**. Intractable Hiccups: **PO** 25-50 mg **TDS**. Palliative Agitation / Nausea: **PO** or **IV** 12.5 - 25 mg q4-8h PRN. Elderly: Start at 10-25 mg/day. High risk of falls and delirium." + }, + { + "label": "Best Uses", + "value": "Chlorpromazine is the original first-generation antipsychotic still used for refractory psychosis and intractable hiccups, but causes severe sedation, photosensitivity, and significant anticholinergic and extrapyramidal effects." + }, + { + "label": "Avoid / Cautions", + "value": "Severe CNS depression, coma, bone marrow depression, narrow-angle glaucoma. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Severe orthostatic hypotension, reflex tachycardia, **QTc** prolongation. Neurological: Profound sedation, hangover, EPS, lowers seizure threshold. Neuroleptic Malignant Syndrome (NMS). Gastrointestinal: Severe anticholinergic toxidrome (constipation, urinary retention, dry mouth). Dermatological: Photosensitivity, blue-grey skin pigmentation (with chronic high-dose use)." + }, + { + "label": "Key Interactions", + "value": "Additive hypotension with BP meds. Additive severe CNS depression with Opioids/Benzos. Additive anticholinergic toxicity with TCAs or Oxybutynin (can trigger toxic megacolon)." + }, + { + "label": "Monitoring", + "value": "Check lying/standing **BP**. Restrict patient to bed rest for 1-2 hours after an acute large dose to prevent syncopal falls. Baseline **ECG**." + }, + { + "label": "Clinical Pearl", + "value": "Chlorpromazine is the only FDA/TGA approved drug for intractable hiccups (lasting > 48 hours). It suppresses the medullary reflex arc that drives the diaphragm spasms." + } + ] + }, + { + "slug": "lurasidone", + "name": "Lurasidone", + "class": "Antipsychotic", + "subclass": "SGA / Benzisothiazol", + "category": "Psychiatry - Oral Antipsychotics", + "accent": "#059669", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "160 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "18 h", + "cls": "", + "flag": "" + }, + { + "label": "Food", + "value": "350 KCAL REQ.", + "cls": "good", + "flag": "warn" + }, + { + "label": "Bipolar Depress.", + "value": "INDICATED", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Second-Generation Antipsychotic with potent 5-HT7 antagonism. Exceptional efficacy for Bipolar Depression. Extremely safe metabolic profile, but requires a strict caloric intake for absorption.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **160 mg/day** (Schizophrenia) or **120 mg/day** (Bipolar Depression).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be taken with a meal of at least 350 calories. If taken on an empty stomach, blood levels drop by 50% and the drug fails.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Lurasidone is an atypical antipsychotic effective for bipolar depression with low metabolic risk, but must be taken with food (350 kcal minimum) and causes akathisia.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Akathisia, EPS (Parkinsonism), somnolence, nausea.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "SAFE — Weight neutral, lipid neutral, glucose neutral. (Often used to reverse weight gain from other SGAs).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Minimal QTc or BP effects.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Bipolar Depression", + "val": "**PO** 20-60 mg **OD** (evening meal). Max 120 mg/day.", + "tags": [] + }, + { + "key": "Schizophrenia", + "val": "**PO** 40-80 mg **OD** (evening meal). Max 160 mg/day.", + "tags": [] + }, + { + "key": "Renal / Hepatic Impairment", + "val": "MANDATORY — Max 80 mg/day if **eGFR** < 50 or moderate hepatic impairment.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Latuda", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (20, 40, 80, 120 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for Schizophrenia. (Often private script for Bipolar Depression in Aus).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia, Bipolar I Depression.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The premier antipsychotic for pulling a patient out of a severe bipolar depressive crash without causing the massive weight gain seen with Quetiapine or Olanzapine.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent use of strong CYP3A4 inhibitors (Ketoconazole) or inducers (Rifampicin).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1. Use only after individual benefit-risk review; avoid describing fetal safety as guaranteed.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Lurasidone pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — **CYP3A4** inhibitors (Diltiazem, Clarithromycin) massively spike lurasidone levels. Maximum lurasidone dose is 40 mg/day if on a moderate inhibitor. Avoid strong inhibitors.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the evening meal contains at least 350 calories. A small salad or an apple is not enough to trigger absorption. It must be a substantial meal.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Baseline **eGFR** to ensure max dose limits.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Pregnancy Shield", + "val": "If a young female with bipolar disorder wishes to become pregnant, switching her from Valproate/Quetiapine to Lurasidone provides exceptional mood stability with Category B1 fetal safety and zero weight gain.", + "tags": [] + }, + { + "key": "The Nausea Fix", + "val": "Lurasidone can cause significant nausea when starting. Taking it strictly in the middle of a heavy dinner heavily blunts the gastric irritation and perfectly aligns with the caloric requirement.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Antagonist at D2 and 5-HT2A. Potent antagonist at 5-HT7 (thought to mediate its unique antidepressant and procognitive effects). High affinity for 5-HT1A (anxiolytic). Zero affinity for histamine (H1) or muscarinic (M1) receptors.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-3 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "18 hours. Extensively metabolised by CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - LATUDA ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Benzisothiazol — Second-Generation Antipsychotic with potent 5-HT7 antagonism." + }, + { + "label": "Route / Formulation", + "value": "Tablets (20, 40, 80, 120 mg). (Latuda)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 20-60 mg **OD** (evening meal). Max 120 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Bipolar Depression: **PO** 20-60 mg **OD** (evening meal). Max 120 mg/day. Schizophrenia: **PO** 40-80 mg **OD** (evening meal). Max 160 mg/day. Renal / Hepatic Impairment: Max 80 mg/day if **eGFR** < 50 or moderate hepatic impairment." + }, + { + "label": "Best Uses", + "value": "Lurasidone is an atypical antipsychotic effective for bipolar depression with low metabolic risk, but must be taken with food (350 kcal minimum) and causes akathisia." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of strong CYP3A4 inhibitors (Ketoconazole) or inducers (Rifampicin). **Pregnancy** Category B1. One of the safest antipsychotics to use in pregnant women." + }, + { + "label": "Key Risks", + "value": "Neurological: Akathisia, EPS (Parkinsonism), somnolence, nausea. Metabolic: Weight neutral, lipid neutral, glucose neutral. (Often used to reverse weight gain from other SGAs). Cardiovascular: Minimal QTc or BP effects." + }, + { + "label": "Key Interactions", + "value": "**CYP3A4** inhibitors (Diltiazem, Clarithromycin) massively spike lurasidone levels. Maximum lurasidone dose is 40 mg/day if on a moderate inhibitor. Avoid strong inhibitors." + }, + { + "label": "Monitoring", + "value": "Ensure the evening meal contains at least 350 calories. A small salad or an apple is not enough to trigger absorption. It must be a substantial meal. Baseline **eGFR** to ensure max dose limits." + }, + { + "label": "Clinical Pearl", + "value": "If a young female with bipolar disorder wishes to become pregnant, switching her from Valproate/Quetiapine to Lurasidone provides exceptional mood stability with Category B1 fetal safety and zero weight gain." + } + ] + }, + { + "slug": "paliperidone-er", + "name": "Paliperidone ER", + "class": "Antipsychotic", + "subclass": "SGA / Active Metabolite", + "category": "Psychiatry - Oral Antipsychotics", + "accent": "#059669", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "12 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "23 h", + "cls": "", + "flag": "" + }, + { + "label": "Prolactin", + "value": "HIGH RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Ghost Pill", + "value": "IN STOOL", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The primary active metabolite of Risperidone (9-hydroxyrisperidone). Formulated in an advanced OROS osmotic pump tablet. Bypasses liver CYP2D6 metabolism entirely.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **12 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Causes intense hyperprolactinemia. The tablet shell does not dissolve; warn the patient they will see the intact pill in their feces.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Paliperidone ER is the active metabolite of risperidone in oral extended-release form with fewer drug interactions, but causes significant hyperprolactinaemia and the shell may appear in stool.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — Severe hyperprolactinemia (galactorrhea, amenorrhea, sexual dysfunction).", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Extrapyramidal side effects (EPS), akathisia, tachycardia (reflex to alpha-1 blockade).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "CAUTION — Do not use in patients with severe bowel strictures (the rigid tablet can cause an obstruction).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia", + "val": "**PO** 3-6 mg **OD** (morning). May increase to Max 12 mg/day.", + "tags": [] + }, + { + "key": "Schizoaffective Disorder", + "val": "**PO** 6 mg **OD**.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — If **eGFR** 50-80, Max 6 mg/day. If **eGFR** 10-50, Max 3 mg/day. Avoid if < 10.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Invega", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Extended Release OROS Tablets (3, 6, 9 mg). MUST be swallowed whole. Never crush or chew.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia, Schizoaffective disorder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Often used as the oral tolerance test before initiating the highly popular Invega Sustenna (LAI depot) injections, or in patients who lack the liver enzyme (CYP2D6) to process Risperidone.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe renal impairment, mechanical bowel obstruction.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Elderly & Dementia", + "val": "CAUTION — Increased mortality risk in dementia-related psychosis.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "SAFE — Because it is not heavily metabolised by CYP450 enzymes, it avoids the massive drug interactions that plague Risperidone (like Fluoxetine or Paroxetine spiking blood levels).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Check **eGFR** before initiation. Monitor serum Prolactin if symptoms develop.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Inform the patient about the ghost pill in the stool to prevent panic that the drug 'isn't working'.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Liver Bypass", + "val": "In a patient with severe liver cirrhosis or taking multiple interacting drugs (like strong SSRIs), regular Risperidone will accumulate and cause severe toxicity. Paliperidone bypasses this by relying on the kidneys, making it much safer in complex hepatic or polypharmacy patients.", + "tags": [] + }, + { + "key": "Schizoaffective Anchor", + "val": "Paliperidone is one of the few antipsychotics with specific, robust evidence and TGA approval as a monotherapy for schizoaffective disorder.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Strong D2 and 5-HT2A receptor antagonist. The OROS osmotic pump slowly pushes the drug out of a laser-drilled hole over 24 hours, providing a perfectly flat blood level without peaks or troughs.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 24 hours to peak (Steady state takes 4-5 days).", + "tags": [] + }, + { + "key": "Half-life", + "val": "23 hours. Cleared ~60% unchanged by the kidneys (bypasses massive liver metabolism).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - INVEGA ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Active Metabolite — The primary active metabolite of Risperidone (9-hydroxyrisperidone)." + }, + { + "label": "Route / Formulation", + "value": "Extended Release OROS Tablets (3, 6, 9 mg). MUST be swallowed whole. Never crush or chew. (Invega)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 3-6 mg **OD** (morning). May increase to Max 12 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia: **PO** 3-6 mg **OD** (morning). May increase to Max 12 mg/day. Schizoaffective Disorder: **PO** 6 mg **OD**. Renal Impairment: If **eGFR** 50-80, Max 6 mg/day. If **eGFR** 10-50, Max 3 mg/day. Avoid if < 10." + }, + { + "label": "Best Uses", + "value": "Paliperidone ER is the active metabolite of risperidone in oral extended-release form with fewer drug interactions, but causes significant hyperprolactinaemia and the shell may appear in stool." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal impairment, mechanical bowel obstruction." + }, + { + "label": "Key Risks", + "value": "Endocrine: Severe hyperprolactinemia (galactorrhea, amenorrhea, sexual dysfunction). Neurological: Extrapyramidal side effects (EPS), akathisia, tachycardia (reflex to alpha-1 blockade). Gastrointestinal: Do not use in patients with severe bowel strictures (the rigid tablet can cause an obstruction)." + }, + { + "label": "Key Interactions", + "value": "Because it is not heavily metabolised by CYP450 enzymes, it avoids the massive drug interactions that plague Risperidone (like Fluoxetine or Paroxetine spiking blood levels)." + }, + { + "label": "Monitoring", + "value": "Check **eGFR** before initiation. Monitor serum Prolactin if symptoms develop. Inform the patient about the ghost pill in the stool to prevent panic that the drug 'isn't working'." + }, + { + "label": "Clinical Pearl", + "value": "In a patient with severe liver cirrhosis or taking multiple interacting drugs (like strong SSRIs), regular Risperidone will accumulate and cause severe toxicity. Paliperidone bypasses this by relying on the kidneys, making it much safer in complex hepatic or polypharmacy patients." + } + ] + }, + { + "slug": "periciazine", + "name": "Periciazine", + "class": "Antipsychotic", + "subclass": "FGA / Phenothiazine", + "category": "Psychiatry - Oral Antipsychotics", + "accent": "#2563eb", + "tag": "LOW-POTENCY FGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "75 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10-20 h", + "cls": "", + "flag": "" + }, + { + "label": "Sedation", + "value": "SEVERE", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Orthostasis", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Low-potency phenothiazine. Heavily sedating. Primarily used for acute behavioral disturbances and severe insomnia in psychiatric settings rather than as a primary antipsychotic.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **75 mg/day** (Usually given as 2.5 - 10 mg PRN).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "High risk of orthostatic hypotension and anticholinergic delirium in the elderly. Often prescribed inappropriately as a 'sleeping pill'.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Periciazine is a low-potency phenothiazine antipsychotic used for behavioural disturbance, but causes significant sedation and anticholinergic effects with limited antipsychotic efficacy.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Profound sedation, hangover, EPS (less than high-potency FGAs like Haldol, but still present).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Orthostatic hypotension, tachycardia, **QTc** prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Dry mouth, constipation (Anticholinergic toxidrome).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Behavioral Disturbance / Aggression", + "val": "**PO** 10-20 mg **BD** to **TDS**. Max 75 mg/day.", + "tags": [] + }, + { + "key": "Agitation (Elderly)", + "val": "MANDATORY — Start at 2.5 mg. Increase to max 10 mg/day strictly under supervision.", + "tags": [] + }, + { + "key": "Insomnia (Off-Label)", + "val": "**PO** 2.5-10 mg **NOCTE**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Neulactil", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (2.5 mg, 10 mg). Oral liquid drops (10 mg/mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia, acute severe behavioral disturbances, severe impulsivity/aggression.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "A common oral 'rescue' or PRN medication on psychiatric wards to settle agitated patients without needing injections.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Severe CNS depression, narrow-angle glaucoma, severe cardiac failure.", + "tags": [] + }, + { + "key": "Elderly", + "val": "CRITICAL — High risk of falls, stroke, and mortality in dementia-related psychosis.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive hypotension and sedation with antihypertensives, Opioids, and Benzos.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor lying and standing **BP**. Implement falls precautions.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The PRN Trap", + "val": "Because it is so sedating, doctors often write Periciazine 10mg PRN for sleep. In the elderly, this causes massive morning hypotension, anticholinergic confusion, and fractured hips. Use a safer alternative (like low-dose Mirtazapine or Temazepam) if possible.", + "tags": [] + }, + { + "key": "The Liquid Burn", + "val": "The oral drops are highly concentrated and can cause contact dermatitis if spilled on the nurse's hands. Always dilute the drops in water/juice before giving to the patient to prevent throat irritation.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Low-affinity D2 antagonist. Very high affinity for H1 (histamine) and Alpha-1 receptors, driving its intense sedating and hypotensive profile.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10-20 hours. Hepatically metabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - NEULACTIL ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "FGA / Phenothiazine — Low-potency phenothiazine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (2.5 mg, 10 mg). Oral liquid drops (10 mg/mL). (Neulactil)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10-20 mg **BD** to **TDS**. Max 75 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Severe Behavioral Disturbance / Aggression: **PO** 10-20 mg **BD** to **TDS**. Max 75 mg/day. Agitation (Elderly): Start at 2.5 mg. Increase to max 10 mg/day strictly under supervision. Insomnia (Off-Label): **PO** 2.5-10 mg **NOCTE**." + }, + { + "label": "Best Uses", + "value": "Periciazine is a low-potency phenothiazine antipsychotic used for behavioural disturbance, but causes significant sedation and anticholinergic effects with limited antipsychotic efficacy." + }, + { + "label": "Avoid / Cautions", + "value": "Severe CNS depression, narrow-angle glaucoma, severe cardiac failure." + }, + { + "label": "Key Risks", + "value": "Neurological: Profound sedation, hangover, EPS (less than high-potency FGAs like Haldol, but still present). Cardiovascular: Orthostatic hypotension, tachycardia, **QTc** prolongation. Gastrointestinal: Dry mouth, constipation (Anticholinergic toxidrome)." + }, + { + "label": "Key Interactions", + "value": "Additive hypotension and sedation with antihypertensives, Opioids, and Benzos." + }, + { + "label": "Monitoring", + "value": "Monitor lying and standing **BP**. Implement falls precautions." + }, + { + "label": "Clinical Pearl", + "value": "Because it is so sedating, doctors often write Periciazine 10mg PRN for sleep. In the elderly, this causes massive morning hypotension, anticholinergic confusion, and fractured hips. Use a safer alternative (like low-dose Mirtazapine or Temazepam) if possible." + } + ] + }, + { + "slug": "trifluoperazine", + "name": "Trifluoperazine", + "class": "Antipsychotic", + "subclass": "FGA / Phenothiazine", + "category": "Psychiatry - Oral Antipsychotics", + "accent": "#2563eb", + "tag": "FGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "30 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "18 h", + "cls": "", + "flag": "" + }, + { + "label": "EPS Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Anxiety", + "value": "OFF-LABEL", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "High-potency phenothiazine. Structurally similar to prochlorperazine. Highly activating and non-sedating, but carries a brutal risk of extrapyramidal side effects.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **30 mg/day** (For schizophrenia). Used in micro-doses (1-2 mg) for anxiety.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Causes intense Parkinsonism and dystonia. Almost always requires co-prescription of an anticholinergic (benztropine).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Trifluoperazine is a high-potency first-generation antipsychotic for schizophrenia and severe anxiety, but causes marked extrapyramidal effects and tardive dyskinesia with long-term use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Severe EPS (Parkinsonism, acute dystonia, akathisia). Tardive Dyskinesia risk is exceptionally high. Neuroleptic Malignant Syndrome (NMS).", + "tags": [] + }, + { + "key": "Endocrine", + "val": "HIGH — Hyperprolactinemia (galactorrhea, amenorrhea).", + "tags": [] + }, + { + "key": "Ocular", + "val": "LOW — Retinal pigmentation (with prolonged high-dose use).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia", + "val": "Start **PO** 5 mg **BD**. Titrate up to 15-20 mg/day. Max 30 mg/day.", + "tags": [] + }, + { + "key": "Severe Anxiety / Nausea (Off-Label)", + "val": "**PO** 1-2 mg **BD**.", + "tags": [] + }, + { + "key": "Elderly", + "val": "MANDATORY — Start at 1 mg. Highly sensitive to EPS.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Stelazine", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (1 mg, 5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia, severe behavioral disturbances.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Severe generalized anxiety unresponsive to standard treatments, severe nausea.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "A high-potency alternative to Haloperidol. Rarely used as first-line today due to the safer profile of SGAs.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Parkinson's disease, severe CNS depression, severe hepatic impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Avoid concurrent QTc prolonging drugs.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — SSRIs (Fluoxetine) increase levels, worsening EPS.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor for rigidity and tremor. Chart PRN Benzatropine.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor serum Prolactin if symptoms develop.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Activating Phenothiazine", + "val": "While most phenothiazines (like Chlorpromazine) turn patients into zombies, Trifluoperazine is 'activating' and alerting. It is useful for withdrawn, apathetic schizophrenic patients, but terrible for agitated ones.", + "tags": [] + }, + { + "key": "The Anxiety Micro-Dose", + "val": "In the 1970s, it was marketed heavily for anxiety (1mg dose). While effective, the long-term risk of irreversible Tardive Dyskinesia (involuntary facial twitching) makes using antipsychotics for simple anxiety highly dangerous.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent central D2 receptor antagonist. Very weak affinity for H1 or Alpha-1 receptors, meaning it causes almost zero sedation or hypotension compared to Chlorpromazine.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-2 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "18 hours. Hepatically metabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - STELAZINE cancellation evidence and PBS search checked 2026-05-12 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "FGA / Phenothiazine — High-potency phenothiazine." + }, + { + "label": "Route / Formulation", + "value": "Tablets (1 mg, 5 mg). (Stelazine)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 5 mg **BD**. Titrate up to 15-20 mg/day. Max 30 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia: Start **PO** 5 mg **BD**. Titrate up to 15-20 mg/day. Max 30 mg/day. Severe Anxiety / Nausea (Off-Label): **PO** 1-2 mg **BD**. Elderly: Start at 1 mg. Highly sensitive to EPS." + }, + { + "label": "Best Uses", + "value": "Trifluoperazine is a high-potency first-generation antipsychotic for schizophrenia and severe anxiety, but causes marked extrapyramidal effects and tardive dyskinesia with long-term use." + }, + { + "label": "Avoid / Cautions", + "value": "Parkinson's disease, severe CNS depression, severe hepatic impairment. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: Severe EPS (Parkinsonism, acute dystonia, akathisia). Tardive Dyskinesia risk is exceptionally high. Neuroleptic Malignant Syndrome (NMS). Endocrine: Hyperprolactinemia (galactorrhea, amenorrhea). Ocular: Retinal pigmentation (with prolonged high-dose use)." + }, + { + "label": "Key Interactions", + "value": "Avoid concurrent QTc prolonging drugs. SSRIs (Fluoxetine) increase levels, worsening EPS." + }, + { + "label": "Monitoring", + "value": "Monitor for rigidity and tremor. Chart PRN Benzatropine. Monitor serum Prolactin if symptoms develop." + }, + { + "label": "Clinical Pearl", + "value": "While most phenothiazines (like Chlorpromazine) turn patients into zombies, Trifluoperazine is 'activating' and alerting. It is useful for withdrawn, apathetic schizophrenic patients, but terrible for agitated ones." + } + ] + }, + { + "slug": "ziprasidone", + "name": "Ziprasidone", + "class": "Antipsychotic", + "subclass": "SGA / Benzisothiazolyl", + "category": "Psychiatry - Oral Antipsychotics", + "accent": "#059669", + "tag": "SGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "160 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "7 h", + "cls": "", + "flag": "" + }, + { + "label": "QTc Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Food", + "value": "500 KCAL REQ.", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Second-Generation Antipsychotic (SGA). Highly weight-neutral and non-sedating, but structurally infamous for dose-dependent QTc prolongation and strict caloric absorption requirements.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **160 mg/day** (e.g., 80 mg BD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be taken with a substantial meal (> 500 calories). If taken on an empty stomach, absorption drops by 50% and the patient will relapse into psychosis.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ziprasidone is an atypical antipsychotic with low metabolic risk, but carries the highest QTc prolongation risk of the atypicals and must be taken with food for adequate absorption.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — **QTc** prolongation. Carries one of the highest baseline QTc prolongation risks of the oral SGAs. Torsades de Pointes risk.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Neurological", + "val": "MODERATE — Akathisia, extrapyramidal side effects (EPS), insomnia, dizziness.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "SAFE — Excellent metabolic profile. Weight-neutral, lipid-neutral.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia / Bipolar Mania", + "val": "Start **PO** 40 mg **BD** WITH FOOD. Titrate to 80 mg **BD**. Max 160 mg/day.", + "tags": [] + }, + { + "key": "Renal / Hepatic Impairment", + "val": "SAFE — No dose adjustment required in renal failure. Hepatic clearance is robust.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zeldox", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules (20, 40, 60, 80 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia, Bipolar I mania or mixed episodes.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Preferred for patients who suffer severe weight gain or dyslipidemia on Olanzapine/Quetiapine, provided they have a healthy heart.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Recent myocardial infarction, uncompensated heart failure, baseline **QTc** > 500 ms, concurrent use of other QTc-prolonging drugs (e.g., Sotalol, Amiodarone, Macrolides).", + "tags": [], + "patient": { + "factors": ["qtc", "allergy-macrolide"], + "action": "contraindication", + "severity": "danger", + "match": { + "qtc": { + "gte": 500 + } + }, + "note": "Ziprasidone contraindication row uses a QTc danger threshold of 500 ms; lower QTc prolongation remains a caution/monitoring prompt elsewhere." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Ziprasidone pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive QTc prolongation with SSRIs, TCAs, and antiarrhythmics.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP3A4** inhibitors (Ketoconazole) increase levels; inducers (Carbamazepine) drastically reduce levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Cardiac", + "val": "MANDATORY — Baseline and routine **ECG** to measure QTc interval. Monitor **U&E** (potassium/magnesium must be normal).", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Bedside", + "val": "MANDATORY — Ensure the patient is actually eating a heavy meal with the dose.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Calorie Counter", + "val": "Ziprasidone is highly lipophilic. If a patient takes it with a piece of toast or a black coffee, it will pass through unabsorbed. It physically requires a ~500 kcal, fat-containing meal to dissolve and enter the blood.", + "tags": [] + }, + { + "key": "The Activating Edge", + "val": "Because it blocks noradrenaline/serotonin reuptake, it can be activating. Avoid giving the second dose right before bed if it causes insomnia; shift it to dinner time.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Antagonist at D2 and 5-HT2A receptors. Also acts as a 5-HT1A agonist and blocks serotonin/noradrenaline reuptake (mild antidepressant effect).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 1-3 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "7 hours (Requires strictly **BD** dosing). Metabolised by aldehyde oxidase and CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ZELDOX ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SGA / Benzisothiazolyl — Second-Generation Antipsychotic (SGA)." + }, + { + "label": "Route / Formulation", + "value": "Capsules (20, 40, 60, 80 mg). (Zeldox)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 40 mg **BD** WITH FOOD. Titrate to 80 mg **BD**. Max 160 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia / Bipolar Mania: Start **PO** 40 mg **BD** WITH FOOD. Titrate to 80 mg **BD**. Max 160 mg/day. Renal / Hepatic Impairment: No dose adjustment required in renal failure. Hepatic clearance is robust." + }, + { + "label": "Best Uses", + "value": "Ziprasidone is an atypical antipsychotic with low metabolic risk, but carries the highest QTc prolongation risk of the atypicals and must be taken with food for adequate absorption." + }, + { + "label": "Avoid / Cautions", + "value": "Recent myocardial infarction, uncompensated heart failure, baseline **QTc** > 500 ms, concurrent use of other QTc-prolonging drugs (e.g., Sotalol, Amiodarone, Macrolides). **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: **QTc** prolongation. Carries one of the highest baseline QTc prolongation risks of the oral SGAs. Torsades de Pointes risk. Neurological: Akathisia, extrapyramidal side effects (EPS), insomnia, dizziness. Metabolic: Excellent metabolic profile. Weight-neutral, lipid-neutral." + }, + { + "label": "Key Interactions", + "value": "Additive QTc prolongation with SSRIs, TCAs, and antiarrhythmics. **CYP3A4** inhibitors (Ketoconazole) increase levels; inducers (Carbamazepine) drastically reduce levels." + }, + { + "label": "Monitoring", + "value": "Baseline and routine **ECG** to measure QTc interval. Monitor **U&E** (potassium/magnesium must be normal). Ensure the patient is actually eating a heavy meal with the dose." + }, + { + "label": "Clinical Pearl", + "value": "Ziprasidone is highly lipophilic. If a patient takes it with a piece of toast or a black coffee, it will pass through unabsorbed. It physically requires a ~500 kcal, fat-containing meal to dissolve and enter the blood." + } + ] + }, + { + "slug": "zuclopenthixol", + "name": "Zuclopenthixol", + "class": "Antipsychotic", + "subclass": "FGA / Thioxanthene", + "category": "Psychiatry - Oral Antipsychotics", + "accent": "#2563eb", + "tag": "FGA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "150 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "20 h", + "cls": "", + "flag": "" + }, + { + "label": "Sedation", + "value": "MODERATE", + "cls": "warn", + "flag": "" + }, + { + "label": "EPS Risk", + "value": "HIGH", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Oral tablet formulation of Zuclopenthixol. Potent FGA used for acute and chronic schizophrenia, particularly when patients exhibit significant aggression or agitation.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **150 mg/day** (Usually 20-40 mg/day).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Often used as the oral 'trial' to ensure the patient tolerates the drug before locking them into the 4-weekly Clopixol Depot injection.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Zuclopenthixol is a thioxanthene antipsychotic for schizophrenia and aggressive behaviour, but causes significant extrapyramidal effects and has depot formulations with prolonged irreversible action.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — High risk of Extrapyramidal Side Effects (Parkinsonism, acute dystonia, severe akathisia), Tardive dyskinesia. HIGH — Sedation.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Orthostatic hypotension, tachycardia, **QTc** prolongation.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Endocrine", + "val": "MODERATE — Hyperprolactinemia.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Schizophrenia / Mania", + "val": "Start **PO** 10 mg **OD** to **BD**. Titrate to 20-40 mg/day. Max 150 mg/day in severe, refractory cases.", + "tags": [] + }, + { + "key": "Elderly", + "val": "MANDATORY — Start at 2-5 mg/day. High risk of EPS and sedation.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Clopixol", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg, 25 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Schizophrenia and other psychoses, especially when accompanied by severe agitation, restlessness, or hostility.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The foundational oral step before transitioning to Clopixol Depot or Acuphase.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Parkinson's disease, severe CNS depression/coma.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category C.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Zuclopenthixol pregnancy row is treated as a source-backed benefit-risk caution, not as an automatic absolute contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP2D6** inhibitors (Fluoxetine, Paroxetine, Bupropion) massively increase zuclopenthixol levels, triggering severe EPS.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive sedation with CNS depressants.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor aggressively for EPS (stiffness, tremor). A PRN anticholinergic (Benzatropine) should be charted when initiating high doses.", + "tags": [] + }, + { + "key": "Cardiac", + "val": "Baseline **ECG** (QTc check).", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "monitor", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Depot Gateway", + "val": "Never give a patient a Clopixol Depot (which lasts 4 weeks) if they have never had the drug before. If they have a severe allergic or dystonic reaction, you cannot get the depot out of their muscle. Always give oral Zuclopenthixol for a few days first to prove tolerance.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Thioxanthene derivative. Potent D2 and 5-HT2A antagonist. Moderate affinity for Alpha-1 and H1 receptors (sedating).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 2-4 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "20 hours. Hepatically metabolised by CYP2D6.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - CLOPIXOL oral ARTG/PI and PBS search checked 2026-05-10 for antipsychotic/LAI batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "FGA / Thioxanthene — Oral tablet formulation of Zuclopenthixol." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg, 25 mg). (Clopixol)" + }, + { + "label": "Usual Dose & Max", + "value": "Start **PO** 10 mg **OD** to **BD**. Titrate to 20-40 mg/day. Max 150 mg/day in severe, refractory cases." + }, + { + "label": "Key Indication Doses", + "value": "Schizophrenia / Mania: Start **PO** 10 mg **OD** to **BD**. Titrate to 20-40 mg/day. Max 150 mg/day in severe, refractory cases. Elderly: Start at 2-5 mg/day. High risk of EPS and sedation." + }, + { + "label": "Best Uses", + "value": "Zuclopenthixol is a thioxanthene antipsychotic for schizophrenia and aggressive behaviour, but causes significant extrapyramidal effects and has depot formulations with prolonged irreversible action." + }, + { + "label": "Avoid / Cautions", + "value": "Parkinson's disease, severe CNS depression/coma. **Pregnancy** Category C." + }, + { + "label": "Key Risks", + "value": "Neurological: High risk of Extrapyramidal Side Effects (Parkinsonism, acute dystonia, severe akathisia), Tardive dyskinesia. HIGH — Sedation. Cardiovascular: Orthostatic hypotension, tachycardia, **QTc** prolongation. Endocrine: Hyperprolactinemia." + }, + { + "label": "Key Interactions", + "value": "**CYP2D6** inhibitors (Fluoxetine, Paroxetine, Bupropion) massively increase zuclopenthixol levels, triggering severe EPS. Additive sedation with CNS depressants." + }, + { + "label": "Monitoring", + "value": "Monitor aggressively for EPS (stiffness, tremor). A PRN anticholinergic (Benzatropine) should be charted when initiating high doses. Baseline **ECG** (QTc check)." + }, + { + "label": "Clinical Pearl", + "value": "Never give a patient a Clopixol Depot (which lasts 4 weeks) if they have never had the drug before. If they have a severe allergic or dystonic reaction, you cannot get the depot out of their muscle. Always give oral Zuclopenthixol for a few days first to prove tolerance." + } + ] + }, + { + "slug": "beclometasone", + "name": "Beclometasone", + "class": "Steroid", + "subclass": "Topical/Inhaled Glucocorticoid", + "category": "Respiratory - Asthma & COPD", + "accent": "#16a34a", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "800 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-3 h", + "cls": "", + "flag": "" + }, + { + "label": "Extra-Fine", + "value": "DEEP LUNG", + "cls": "good", + "flag": "" + }, + { + "label": "Thrush", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Inhaled Corticosteroid (ICS). Formulated as extra-fine particles that penetrate deep into the small airways, providing excellent control of chronic asthma inflammation.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **800 mcg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must use a spacer and rinse/spit after every dose to prevent oral thrush and vocal cord myopathy.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Beclometasone is a standard inhaled corticosteroid for asthma preventer therapy, but requires consistent use for effect and mouth rinsing to prevent oral candidiasis.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Oral/Pharyngeal", + "val": "HIGH — Oropharyngeal candidiasis, dysphonia (hoarseness).", + "tags": [] + }, + { + "key": "Endocrine", + "val": "LOW — Minimal systemic adrenal suppression at standard doses.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Asthma Maintenance", + "val": "**Inhaled** 100-400 mcg **BD**. Titrate to lowest effective dose.", + "tags": [] + }, + { + "key": "Combo Therapy", + "val": "Often combined with Formoterol (Fostair) for MART regimens.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Qvar, Fostair (combo)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Metered Dose Inhaler (50, 100 mcg/actuation).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment of asthma.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line preventer. The extra-fine particle formulation (Qvar) means 100mcg of Beclometasone provides the same lung effect as 200mcg of older ICS formulations.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Acute asthma attacks (preventer, not a reliever).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3; avoid/initiate only if the expected benefit outweighs fetal risk.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Beclometasone pregnancy row should prompt benefit-risk review rather than automatic contraindication." + } + }, + { + "key": "Paediatric", + "val": "CAUTION — Do not use QVAR in children < 5 years; safety and effectiveness are not established.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 5 + } + }, + "note": "QVAR should not be used in children younger than 5 years because safety/effectiveness are not established." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "MODERATE — CYP3A4 inhibitors can slightly raise systemic levels, but much less dangerous than with Fluticasone.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure 'rinse and spit' routine to prevent thrush.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Small Airways", + "val": "Asthma isn't just in the big bronchi; it affects the tiny terminal bronchioles. The ultra-fine particles of Qvar (Beclometasone) physically reach deeper into the lungs than standard Flixotide, offering superior control in difficult cases.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Glucocorticoid receptor agonist. Suppresses airway inflammation, reduces mucosal oedema, and decreases hyper-responsiveness.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks for full effect.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours. High first-pass metabolism minimizes systemic absorption of the swallowed fraction.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: QVAR/beclometasone Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Topical/Inhaled Glucocorticoid — Inhaled Corticosteroid (ICS)." + }, + { + "label": "Route / Formulation", + "value": "Metered Dose Inhaler (50, 100 mcg/actuation). (Qvar, Fostair (combo))" + }, + { + "label": "Usual Dose & Max", + "value": "**Inhaled** 100-400 mcg **BD**. Titrate to lowest effective dose. Max **800 mcg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Asthma Maintenance: **Inhaled** 100-400 mcg **BD**. Titrate to lowest effective dose. Combo Therapy: Often combined with Formoterol (Fostair) for MART regimens." + }, + { + "label": "Best Uses", + "value": "Beclometasone is a standard inhaled corticosteroid for asthma preventer therapy, but requires consistent use for effect and mouth rinsing to prevent oral candidiasis." + }, + { + "label": "Avoid / Cautions", + "value": "Acute asthma attacks (preventer, not a reliever). **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Oral/Pharyngeal: Oropharyngeal candidiasis, dysphonia (hoarseness). Endocrine: Minimal systemic adrenal suppression at standard doses." + }, + { + "label": "Key Interactions", + "value": "CYP3A4 inhibitors can slightly raise systemic levels, but much less dangerous than with Fluticasone." + }, + { + "label": "Monitoring", + "value": "Ensure 'rinse and spit' routine to prevent thrush." + }, + { + "label": "Clinical Pearl", + "value": "Asthma isn't just in the big bronchi; it affects the tiny terminal bronchioles. The ultra-fine particles of Qvar (Beclometasone) physically reach deeper into the lungs than standard Flixotide, offering superior control in difficult cases." + } + ] + }, + { + "slug": "budesonide", + "name": "Budesonide", + "class": "Steroid", + "subclass": "Inhaled Glucocorticoid", + "category": "Respiratory - Asthma & COPD", + "accent": "#16a34a", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "800 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-3 h", + "cls": "", + "flag": "" + }, + { + "label": "Thrush", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + }, + { + "label": "Wash Mouth", + "value": "MANDATORY", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Inhaled Corticosteroid (ICS). The cornerstone of asthma prevention and chronic inflammation control in the airways.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **800 mcg/day** (Doses > 800 mcg/day provide little extra local benefit but drastically increase systemic absorption/side effects).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must rinse and spit after every use to prevent severe oropharyngeal candidiasis (oral thrush).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Budesonide is a first-line inhaled corticosteroid for asthma and COPD with good local potency, but oral candidiasis requires mouth rinsing after every dose.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Oral/Pharyngeal", + "val": "HIGH — Oropharyngeal candidiasis (thrush), dysphonia (hoarse voice).", + "tags": [] + }, + { + "key": "Endocrine", + "val": "MODERATE — At high doses (>800 mcg/day), systemic absorption can cause adrenal suppression, reduced bone mineral density, and skin thinning.", + "tags": [] + }, + { + "key": "Ocular", + "val": "LOW — Increased risk of cataracts/glaucoma with long-term high-dose use.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Asthma Maintenance", + "val": "**Inhaled** 100-400 mcg **BD**. (Often combined with formoterol as Symbicort).", + "tags": [] + }, + { + "key": "Croup (Paediatrics)", + "val": "**Inhaled** 2 mg via nebuliser STAT.", + "tags": [] + }, + { + "key": "Eosinophilic Esophagitis", + "val": "**PO** (Off-label) Slurry made from respules, swallowed.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Pulmicort, Symbicort (combo)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Dry powder inhaler (Turbuhaler 100 mcg, 200 mcg, 400 mcg). Nebules (1 mg/2 mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Asthma maintenance, COPD maintenance (in severe cases with frequent exacerbations).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Eosinophilic esophagitis, Croup.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "First-line preventative therapy for any patient requiring a SABA more than twice a month.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Status asthmaticus (does not provide acute relief).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. Widely studied and highly safe in pregnancy.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Budesonide pregnancy row is informational/safe-use context and should not trigger a danger alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong **CYP3A4** inhibitors (Itraconazole, Ritonavir) can drastically increase systemic budesonide levels, leading to Cushing's syndrome and adrenal suppression.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Inspect oral cavity for white plaques (thrush). Check inhaler technique.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required for standard doses.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Rinse and Spit", + "val": "The vast majority of an ICS puff hits the back of the throat. Rinsing the mouth and spitting out the water washes away the drug, preventing thrush and preventing it from being swallowed into the systemic circulation.", + "tags": [] + }, + { + "key": "The Croup Dose", + "val": "Nebulised budesonide (2mg STAT) is a rapid and highly effective alternative to oral dexamethasone in a vomiting child with acute croup.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent glucocorticoid that enters airway cells, binds to glucocorticoid receptors, and alters gene transcription to suppress inflammatory cytokines and reduce airway hyper-responsiveness.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks for full effect.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours. High first-pass metabolism minimizes systemic effects of swallowed fraction.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: PULMICORT/budesonide Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Inhaled Glucocorticoid — Inhaled Corticosteroid (ICS)." + }, + { + "label": "Route / Formulation", + "value": "Dry powder inhaler (Turbuhaler 100 mcg, 200 mcg, 400 mcg). Nebules (1 mg/2 mL). (Pulmicort, Symbicort (combo))" + }, + { + "label": "Usual Dose & Max", + "value": "**Inhaled** 100-400 mcg **BD**. (Often combined with formoterol as Symbicort). Max **800 mcg/day** (Doses > 800 mcg/day provide little extra local benefit but drastically increase systemic absorption/side effects)." + }, + { + "label": "Key Indication Doses", + "value": "Asthma Maintenance: **Inhaled** 100-400 mcg **BD**. (Often combined with formoterol as Symbicort). Croup (Paediatrics): **Inhaled** 2 mg via nebuliser STAT. Eosinophilic Esophagitis: **PO** (Off-label) Slurry made from respules, swallowed." + }, + { + "label": "Best Uses", + "value": "Budesonide is a first-line inhaled corticosteroid for asthma and COPD with good local potency, but oral candidiasis requires mouth rinsing after every dose." + }, + { + "label": "Avoid / Cautions", + "value": "Status asthmaticus (does not provide acute relief). **Pregnancy** Category A. Widely studied and highly safe in pregnancy." + }, + { + "label": "Key Risks", + "value": "Oral/Pharyngeal: Oropharyngeal candidiasis (thrush), dysphonia (hoarse voice). Endocrine: At high doses (>800 mcg/day), systemic absorption can cause adrenal suppression, reduced bone mineral density, and skin thinning. Ocular: Increased risk of cataracts/glaucoma with long-term high-dose use." + }, + { + "label": "Key Interactions", + "value": "Strong **CYP3A4** inhibitors (Itraconazole, Ritonavir) can drastically increase systemic budesonide levels, leading to Cushing's syndrome and adrenal suppression." + }, + { + "label": "Monitoring", + "value": "Inspect oral cavity for white plaques (thrush). Check inhaler technique. No specific routine laboratory tests required for standard doses." + }, + { + "label": "Clinical Pearl", + "value": "The vast majority of an ICS puff hits the back of the throat. Rinsing the mouth and spitting out the water washes away the drug, preventing thrush and preventing it from being swallowed into the systemic circulation." + } + ] + }, + { + "slug": "ciclesonide", + "name": "Ciclesonide", + "class": "Steroid", + "subclass": "Inhaled Glucocorticoid", + "category": "Respiratory - Asthma & COPD", + "accent": "#16a34a", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "320 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "0.5 h (Active)", + "cls": "", + "flag": "" + }, + { + "label": "Prodrug", + "value": "LUNG ACTIVATED", + "cls": "good", + "flag": "" + }, + { + "label": "Thrush", + "value": "LOW RISK", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "A brilliant 'pro-drug' inhaled corticosteroid. It is completely inactive in the mouth/throat, and only becomes active once it hits enzymes deep in the lungs. Massively reduces oral thrush risk.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **320 mcg/day** (Usually 160 mcg OD).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "The safest ICS regarding systemic and oral side effects. Can be dosed once daily.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ciclesonide is a prodrug ICS activated in the lungs with minimal oropharyngeal deposition, but is more expensive and offers no clear efficacy advantage over budesonide/fluticasone.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Oral/Pharyngeal", + "val": "LOW — Thrush and dysphonia are exceedingly rare due to the prodrug nature.", + "tags": [] + }, + { + "key": "Endocrine", + "val": "SAFE — Systemic adrenal suppression is virtually zero at standard doses.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Asthma Maintenance", + "val": "**Inhaled** 80-160 mcg **OD** (Preferably in the evening). Max 320 mcg/day in severe cases.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Alvesco", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Metered Dose Inhaler (80, 160 mcg/actuation).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment of asthma in adults, adolescents, and children 6 years and older.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The absolute best choice for patients who chronically suffer from oral thrush or hoarse voice on other steroid inhalers.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Acute bronchospasm.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3 (budesonide has more established pregnancy experience).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Ciclesonide pregnancy row should prompt benefit-risk review rather than automatic contraindication." + } + }, + { + "key": "Paediatric", + "val": "CAUTION — Not indicated in children < 6 years.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "caution", + "severity": "caution", + "match": { + "age": { + "lt": 6 + } + }, + "note": "Ciclesonide asthma indication is for children 6 years and older." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Negligible clinical interactions.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure patient understands this is a preventer, not a reliever.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Singer's Choice", + "val": "Because it is inactive in the throat, Ciclesonide does not cause the vocal cord myopathy (hoarseness/voice changes) that plagues budesonide and fluticasone. It is the inhaler of choice for singers, teachers, and broadcasters.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inactive prodrug. Cleaved exclusively by esterase enzymes located deep in the pulmonary epithelium into the active metabolite (desisobutyryl-ciclesonide), which binds the glucocorticoid receptor.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "0.5 hours (Active metabolite). Swallowed drug is >99% destroyed by the liver instantly.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ALVESCO/ciclesonide Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Inhaled Glucocorticoid — A brilliant 'pro-drug' inhaled corticosteroid." + }, + { + "label": "Route / Formulation", + "value": "Metered Dose Inhaler (80, 160 mcg/actuation). (Alvesco)" + }, + { + "label": "Usual Dose & Max", + "value": "**Inhaled** 80-160 mcg **OD** (Preferably in the evening). Max 320 mcg/day in severe cases." + }, + { + "label": "Best Uses", + "value": "Ciclesonide is a prodrug ICS activated in the lungs with minimal oropharyngeal deposition, but is more expensive and offers no clear efficacy advantage over budesonide/fluticasone." + }, + { + "label": "Avoid / Cautions", + "value": "Acute bronchospasm. **Pregnancy** Category B3 (Budesonide preferred due to more historical data)." + }, + { + "label": "Key Risks", + "value": "Oral/Pharyngeal: Thrush and dysphonia are exceedingly rare due to the prodrug nature. Endocrine: Systemic adrenal suppression is virtually zero at standard doses." + }, + { + "label": "Key Interactions", + "value": "Negligible clinical interactions." + }, + { + "label": "Monitoring", + "value": "Ensure patient understands this is a preventer, not a reliever." + }, + { + "label": "Clinical Pearl", + "value": "Because it is inactive in the throat, Ciclesonide does not cause the vocal cord myopathy (hoarseness/voice changes) that plagues budesonide and fluticasone. It is the inhaler of choice for singers, teachers, and broadcasters." + } + ] + }, + { + "slug": "fluticasone", + "name": "Fluticasone", + "class": "Steroid", + "subclass": "Inhaled Glucocorticoid", + "category": "Respiratory - Asthma & COPD", + "accent": "#16a34a", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1000 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "8-14 h", + "cls": "", + "flag": "" + }, + { + "label": "Lipophilic", + "value": "HIGH", + "cls": "warn", + "flag": "" + }, + { + "label": "Systemic Abs.", + "value": "LOW", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly lipophilic, extremely potent inhaled corticosteroid. Stronger receptor binding than budesonide, providing excellent local control with minimal systemic swallowing absorption.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1000 mcg/day** (Adults).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Fluticasone Propionate (Flixotide) and Fluticasone Furoate (Arnuity) have different potencies and dosing regimens. Do not mix them up.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Fluticasone is a highly potent inhaled corticosteroid for moderate-severe asthma, but has greater systemic absorption than budesonide increasing adrenal suppression risk at high doses.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Oral/Pharyngeal", + "val": "HIGH — Oropharyngeal candidiasis, dysphonia.", + "tags": [] + }, + { + "key": "Respiratory", + "val": "MODERATE — Paradoxical bronchospasm upon inhalation (often due to the propellant, use a spacer).", + "tags": [] + }, + { + "key": "Endocrine", + "val": "MODERATE — Adrenal suppression at extremely high doses, though less likely than with Beclometasone due to 99% hepatic clearance of swallowed fractions.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Asthma Maintenance (Propionate)", + "val": "**Inhaled** 100-500 mcg **BD**. Max 1000 mcg/day.", + "tags": [] + }, + { + "key": "Asthma Maintenance (Furoate)", + "val": "**Inhaled** 100-200 mcg **OD**.", + "tags": [] + }, + { + "key": "COPD (Combo only)", + "val": "**Inhaled** Typically given combined with Salmeterol (Seretide) or Vilanterol (Breo).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Flixotide, Seretide (combo), Breo Ellipta (combo)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "MDI (50, 125, 250 mcg/actuation). Dry powder Accuhaler/Ellipta.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Asthma prophylaxis, severe COPD.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly prescribed maintenance inhaler. The Furoate salt allows for ultra-convenient once-daily dosing.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Acute asthma attacks (not a reliever).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3 (budesonide is generally preferred in pregnancy, though fluticasone may be continued if already effective).", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Fluticasone pregnancy row should prompt benefit-risk review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — **CYP3A4** inhibitors (Ritonavir, Cobicistat) completely block hepatic breakdown. Swallowed fluticasone builds up, causing profound iatrogenic Cushing's syndrome and adrenal crisis.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure 'rinse and spit' routine to prevent thrush.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The HIV/Hep C Trap", + "val": "Never prescribe Fluticasone to a patient on HIV/HCV protease inhibitors (Ritonavir). It is a classic exam and ward error resulting in rapid, severe adrenal suppression.", + "tags": [] + }, + { + "key": "Pneumonia in COPD", + "val": "ICS use in COPD (especially Fluticasone) is statistically linked to a higher risk of developing pneumonia. Use ICS in COPD only if they have frequent exacerbations or an eosinophilic phenotype.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent glucocorticoid receptor agonist. Reduces airway inflammation. Modifies gene transcription.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Full effect takes 1-2 weeks.", + "tags": [] + }, + { + "key": "Duration", + "val": "12-24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "8-14 hours. First-pass metabolism is nearly 100%, meaning any drug swallowed is immediately destroyed by the liver, severely restricting systemic side effects.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: FLIXOTIDE/fluticasone Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Inhaled Glucocorticoid — Highly lipophilic, extremely potent inhaled corticosteroid." + }, + { + "label": "Route / Formulation", + "value": "MDI (50, 125, 250 mcg/actuation). Dry powder Accuhaler/Ellipta. (Flixotide, Seretide (combo), Breo Ellipta (combo))" + }, + { + "label": "Usual Dose & Max", + "value": "**Inhaled** 100-500 mcg **BD**. Max 1000 mcg/day." + }, + { + "label": "Key Indication Doses", + "value": "Asthma Maintenance (Propionate): **Inhaled** 100-500 mcg **BD**. Max 1000 mcg/day. Asthma Maintenance (Furoate): **Inhaled** 100-200 mcg **OD**. COPD (Combo only): **Inhaled** Typically given combined with Salmeterol (Seretide) or Vilanterol (Breo)." + }, + { + "label": "Best Uses", + "value": "Fluticasone is a highly potent inhaled corticosteroid for moderate-severe asthma, but has greater systemic absorption than budesonide increasing adrenal suppression risk at high doses." + }, + { + "label": "Avoid / Cautions", + "value": "Acute asthma attacks (not a reliever). **Pregnancy** Category B3 (Budesonide is generally preferred in pregnancy, though fluticasone is continued if the patient is stable on it)." + }, + { + "label": "Key Risks", + "value": "Oral/Pharyngeal: Oropharyngeal candidiasis, dysphonia. Respiratory: Paradoxical bronchospasm upon inhalation (often due to the propellant, use a spacer). Endocrine: Adrenal suppression at extremely high doses, though less likely than with Beclometasone due to 99% hepatic clearance of swallowed fractions." + }, + { + "label": "Key Interactions", + "value": "**CYP3A4** inhibitors (Ritonavir, Cobicistat) completely block hepatic breakdown. Swallowed fluticasone builds up, causing profound iatrogenic Cushing's syndrome and adrenal crisis." + }, + { + "label": "Monitoring", + "value": "Ensure 'rinse and spit' routine to prevent thrush. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Never prescribe Fluticasone to a patient on HIV/HCV protease inhibitors (Ritonavir). It is a classic exam and ward error resulting in rapid, severe adrenal suppression." + } + ] + }, + { + "slug": "formoterol", + "name": "Formoterol", + "class": "Respiratory", + "subclass": "LABA", + "category": "Respiratory - Asthma & COPD", + "accent": "#475569", + "tag": "LABA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "48 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "1-3 mins", + "cls": "good", + "flag": "" + }, + { + "label": "Asthma Mono", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Tremor", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Long-Acting Beta-2 Agonist (LABA) with a uniquely *fast* onset. Used as both maintenance and reliever therapy in asthma (MART regimen).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **48 mcg/day** (up to 72 mcg/day briefly under specialist direction in acute exacerbation).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never prescribe a LABA as monotherapy in asthma (black box warning for asthma-related death). MUST be combined with an inhaled corticosteroid (ICS).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Formoterol is a fast-onset LABA uniquely suitable for both maintenance and reliever therapy (MART with ICS), but must never be used without an ICS due to increased asthma mortality risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "HIGH — Tremor, headache, anxiety.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Palpitations, tachycardia, mild **QTc** prolongation at high doses.", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Metabolic", + "val": "LOW — Hypokalemia (usually only significant if overusing the inhaler).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Asthma (MART Regimen)", + "val": "**Inhaled** Combo with ICS (e.g., Symbicort). Typically 1-2 puffs **BD** maintenance, plus 1 puff **PRN** for relief. Max 12 puffs/day.", + "tags": [] + }, + { + "key": "COPD Maintenance", + "val": "**Inhaled** 12 mcg **BD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Oxis, Foradile, Symbicort (with Budesonide)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Dry powder inhalers, typically 6 mcg or 12 mcg per dose.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Asthma maintenance and reliever (when combined with ICS), COPD maintenance.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Because it works as fast as salbutamol but lasts 12 hours, it is the only LABA approved for 'Maintenance And Reliever Therapy' (MART).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Asthma monotherapy without an ICS.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Formoterol pregnancy row should prompt benefit-risk review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Non-selective beta-blockers antagonise the effect.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive hypokalemia with loop/thiazide diuretics and high-dose corticosteroids.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure patient understands the MART regimen (that their 'preventer' is now also their 'reliever').", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **U&E** (potassium) if the patient is taking frequent PRN doses.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The MART Revolution", + "val": "Symbicort (Budesonide/Formoterol) is taken BD for prevention, but also used PRN for breathlessness. This ensures that every time a patient uses their reliever, they get a dose of steroid to treat the underlying inflammation.", + "tags": [] + }, + { + "key": "Salmeterol Difference", + "val": "Do not confuse Formoterol with Salmeterol. Salmeterol takes 15-30 mins to work and CANNOT be used as a reliever.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Highly selective, lipophilic beta-2 agonist. Concentrates in airway cell membranes and slowly leaches out, providing prolonged bronchodilation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**Inhaled** 1-3 mins (Fast onset, identical to Salbutamol).", + "tags": [] + }, + { + "key": "Duration", + "val": "12 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "8 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: FORADILE/OXIS formoterol Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "LABA — Long-Acting Beta-2 Agonist (LABA) with a uniquely *fast* onset." + }, + { + "label": "Route / Formulation", + "value": "Dry powder inhalers, typically 6 mcg or 12 mcg per dose. (Oxis, Foradile, Symbicort (with Budesonide))" + }, + { + "label": "Usual Dose & Max", + "value": "**Inhaled** Combo with ICS (e.g., Symbicort). Typically 1-2 puffs **BD** maintenance, plus 1 puff **PRN** for relief. Max 12 puffs/day." + }, + { + "label": "Key Indication Doses", + "value": "Asthma (MART Regimen): **Inhaled** Combo with ICS (e.g., Symbicort). Typically 1-2 puffs **BD** maintenance, plus 1 puff **PRN** for relief. Max 12 puffs/day. COPD Maintenance: **Inhaled** 12 mcg **BD**." + }, + { + "label": "Best Uses", + "value": "Formoterol is a fast-onset LABA uniquely suitable for both maintenance and reliever therapy (MART with ICS), but must never be used without an ICS due to increased asthma mortality risk." + }, + { + "label": "Avoid / Cautions", + "value": "Asthma monotherapy without an ICS. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Neurological: Tremor, headache, anxiety. Cardiovascular: Palpitations, tachycardia, mild **QTc** prolongation at high doses. Metabolic: Hypokalemia (usually only significant if overusing the inhaler)." + }, + { + "label": "Key Interactions", + "value": "Non-selective beta-blockers antagonise the effect. Additive hypokalemia with loop/thiazide diuretics and high-dose corticosteroids." + }, + { + "label": "Monitoring", + "value": "Ensure patient understands the MART regimen (that their 'preventer' is now also their 'reliever'). Check **U&E** (potassium) if the patient is taking frequent PRN doses." + }, + { + "label": "Clinical Pearl", + "value": "Symbicort (Budesonide/Formoterol) is taken BD for prevention, but also used PRN for breathlessness. This ensures that every time a patient uses their reliever, they get a dose of steroid to treat the underlying inflammation." + } + ] + }, + { + "slug": "ipratropium", + "name": "Ipratropium", + "class": "Respiratory", + "subclass": "SAMA", + "category": "Respiratory - Asthma & COPD", + "accent": "#475569", + "tag": "SAMA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "2000 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2 h", + "cls": "", + "flag": "" + }, + { + "label": "Glaucoma", + "value": "AVOID SPRAY", + "cls": "hi", + "flag": "" + }, + { + "label": "Dry Mouth", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Short-Acting Muscarinic Antagonist (SAMA). An anticholinergic bronchodilator. Acts purely locally in the airways to dry secretions and block vagal bronchoconstriction.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2000 mcg/day** (via nebuliser).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Escaping nebuliser mist hitting the eyes can precipitate acute angle-closure glaucoma.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ipratropium is a short-acting anticholinergic bronchodilator essential in acute severe asthma (with salbutamol) and COPD, but has slower onset than salbutamol and is not a standalone reliever.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Ocular", + "val": "CRITICAL — Nebulised mist in eyes can cause pupillary dilation and trigger acute angle-closure glaucoma.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Dry mouth, altered taste.", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "MODERATE — Urinary retention (especially in elderly men with BPH).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Asthma (Severe)", + "val": "**Inhaled** 500 mcg via nebuliser every 20 mins for 3 doses (mixed with Salbutamol), then q4-6h.", + "tags": [] + }, + { + "key": "Acute COPD Exacerbation", + "val": "**Inhaled** 500 mcg via nebuliser q4-6h. Often mixed with Salbutamol.", + "tags": [] + }, + { + "key": "Maintenance (MDI)", + "val": "**Inhaled** 2 puffs (21 mcg/puff) QID.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Atrovent, Combivent (combo)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Metered Dose Inhaler (21 mcg/actuation). Nebules (250 mcg/1 mL, 500 mcg/1 mL).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute asthma (severe), COPD maintenance and exacerbations.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Added to SABA therapy for the first 24-48 hours of severe asthma/COPD exacerbations. Rarely used long-term anymore due to superiority of LAMAs (e.g., Tiotropium).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known hypersensitivity to atropine derivatives.", + "tags": [] + }, + { + "key": "Ocular", + "val": "CAUTION — Narrow-angle glaucoma (protect eyes during nebulisation with a mouthpiece or tight-fitting mask).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Ipratropium pregnancy row is informational/safe-use context and should not trigger a danger alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "MODERATE — Additive anticholinergic effects if given with TCAs, sedating antihistamines, or antipsychotics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **SpO2** and **RR**. Ask about eye pain or blurred vision post-nebulisation.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Mask Trap", + "val": "Elderly patients using an ill-fitting nebuliser mask will have the anticholinergic mist blow directly into their eyes. Always use a mouthpiece if possible, or ensure the mask is tightly sealed over the nose bridge.", + "tags": [] + }, + { + "key": "The 24-Hour Rule", + "val": "In acute asthma, Ipratropium only provides additional benefit for the first 24-48 hours. After the acute vagal tone is broken, it should be ceased to prevent mucus plugging.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Non-selective muscarinic antagonist. Blocks acetylcholine at parasympathetic sites in bronchial smooth muscle, preventing bronchoconstriction and reducing mucus secretion.", + "tags": [] + }, + { + "key": "Onset", + "val": "**Inhaled** 15-30 mins (Slower than Salbutamol). Peak at 1-2 hours.", + "tags": [] + }, + { + "key": "Duration", + "val": "4-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2 hours. Poorly absorbed systemically (minimises side effects).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: ATROVENT/ipratropium Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SAMA — Short-Acting Muscarinic Antagonist (SAMA)." + }, + { + "label": "Route / Formulation", + "value": "Metered Dose Inhaler (21 mcg/actuation). Nebules (250 mcg/1 mL, 500 mcg/1 mL). (Atrovent, Combivent (combo))" + }, + { + "label": "Usual Dose & Max", + "value": "**Inhaled** 500 mcg via nebuliser every 20 mins for 3 doses (mixed with Salbutamol), then q4-6h. Max **2000 mcg/day** (via nebuliser)." + }, + { + "label": "Key Indication Doses", + "value": "Acute Asthma (Severe): **Inhaled** 500 mcg via nebuliser every 20 mins for 3 doses (mixed with Salbutamol), then q4-6h. Acute COPD Exacerbation: **Inhaled** 500 mcg via nebuliser q4-6h. Often mixed with Salbutamol. Maintenance (MDI): **Inhaled** 2 puffs (21 mcg/puff) QID." + }, + { + "label": "Best Uses", + "value": "Ipratropium is a short-acting anticholinergic bronchodilator essential in acute severe asthma (with salbutamol) and COPD, but has slower onset than salbutamol and is not a standalone reliever." + }, + { + "label": "Avoid / Cautions", + "value": "Known hypersensitivity to atropine derivatives. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Ocular: Nebulised mist in eyes can cause pupillary dilation and trigger acute angle-closure glaucoma. Gastrointestinal: Dry mouth, altered taste. Genitourinary: Urinary retention (especially in elderly men with BPH)." + }, + { + "label": "Key Interactions", + "value": "Additive anticholinergic effects if given with TCAs, sedating antihistamines, or antipsychotics." + }, + { + "label": "Monitoring", + "value": "Monitor **SpO2** and **RR**. Ask about eye pain or blurred vision post-nebulisation. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Elderly patients using an ill-fitting nebuliser mask will have the anticholinergic mist blow directly into their eyes. Always use a mouthpiece if possible, or ensure the mask is tightly sealed over the nose bridge." + } + ] + }, + { + "slug": "mometasone", + "name": "Mometasone", + "class": "Steroid", + "subclass": "Topical/Inhaled Glucocorticoid", + "category": "Respiratory - Asthma & COPD", + "accent": "#16a34a", + "tag": "STEROID", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "800 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5 h", + "cls": "", + "flag": "" + }, + { + "label": "Systemic Abs.", + "value": "EXTREMELY LOW", + "cls": "good", + "flag": "" + }, + { + "label": "Allergic Rhinitis", + "value": "1ST LINE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly potent glucocorticoid with virtually zero systemic bioavailability. The absolute gold-standard nasal spray for severe allergic rhinitis and nasal polyps.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **800 mcg/day** (Inhaled for asthma). Max **400 mcg/day** (Nasal).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be used continuously to prevent rhinitis. PRN use is ineffective.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Mometasone is a potent corticosteroid available as nasal spray and inhaler for allergic rhinitis and asthma, but systemic absorption at high doses can cause adrenal suppression.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Respiratory (Nasal)", + "val": "MODERATE — Epistaxis (nosebleeds), nasal irritation, mucosal ulceration.", + "tags": [] + }, + { + "key": "Endocrine", + "val": "SAFE — Systemic adrenal suppression is negligible.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Allergic Rhinitis / Hayfever", + "val": "**Nasal** 2 sprays into each nostril **OD** (200 mcg/day). Once controlled, reduce to 1 spray OD.", + "tags": [] + }, + { + "key": "Asthma Maintenance", + "val": "**Inhaled** 200-400 mcg **OD** (often in the evening).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Nasonex (Nasal), Asmanex (Inhaled), Novasone (Topical)", + "tags": [] + }, + { + "key": "Routes", + "val": "Nasal spray (50 mcg/spray). Dry powder inhaler. Topical creams/ointments.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Nasonex is Over The Counter (S2). Asmanex is Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Seasonal/perennial allergic rhinitis, nasal polyps, asthma maintenance.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line therapy for moderate-to-severe hayfever. Vastly superior to oral antihistamines for nasal congestion.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Untreated localized infection of the nasal mucosa (e.g., Herpes simplex).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Mometasone pregnancy row should prompt benefit-risk review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — No clinically significant interactions for the nasal spray.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Teach correct nasal spray technique to avoid epistaxis.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Septum Trap", + "val": "If patients point the spray directly up the middle of their nose, the steroid hits the nasal septum, thinning the blood vessels and causing severe, chronic nosebleeds. Instruct them to point the nozzle OUTWARDS toward the ear (the lateral turbinates) to prevent bleeding and maximize absorption.", + "tags": [] + }, + { + "key": "The Hayfever Cure", + "val": "Oral antihistamines fix sneezing and itching, but do absolutely nothing for a blocked, congested nose. Mometasone nasal spray physically shrinks the inflamed turbinates, curing the congestion.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Potent glucocorticoid receptor agonist. Suppresses local inflammatory cytokines and eosinophil infiltration in the nasal mucosa or lungs.", + "tags": [] + }, + { + "key": "Onset", + "val": "Nasal: 12-48 hours. Lungs: 1-2 weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5 hours. Systemic bioavailability is < 0.1% for the nasal spray.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: NASONEX/mometasone Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Topical/Inhaled Glucocorticoid — Highly potent glucocorticoid with virtually zero systemic bioavailability." + }, + { + "label": "Route / Formulation", + "value": "Nasal spray (50 mcg/spray). Dry powder inhaler. Topical creams/ointments. (Nasonex (Nasal), Asmanex (Inhaled), Novasone (Topical))" + }, + { + "label": "Usual Dose & Max", + "value": "**Nasal** 2 sprays into each nostril **OD** (200 mcg/day). Once controlled, reduce to 1 spray OD. Max **800 mcg/day** (Inhaled for asthma)." + }, + { + "label": "Key Indication Doses", + "value": "Allergic Rhinitis / Hayfever: **Nasal** 2 sprays into each nostril **OD** (200 mcg/day). Once controlled, reduce to 1 spray OD. Asthma Maintenance: **Inhaled** 200-400 mcg **OD** (often in the evening)." + }, + { + "label": "Best Uses", + "value": "Mometasone is a potent corticosteroid available as nasal spray and inhaler for allergic rhinitis and asthma, but systemic absorption at high doses can cause adrenal suppression." + }, + { + "label": "Avoid / Cautions", + "value": "Untreated localized infection of the nasal mucosa (e.g., Herpes simplex). **Pregnancy** Category B3 (but widely considered safe for severe rhinitis due to zero systemic absorption)." + }, + { + "label": "Key Risks", + "value": "Respiratory (Nasal): Epistaxis (nosebleeds), nasal irritation, mucosal ulceration. Endocrine: Systemic adrenal suppression is negligible." + }, + { + "label": "Key Interactions", + "value": "No clinically significant interactions for the nasal spray." + }, + { + "label": "Monitoring", + "value": "Teach correct nasal spray technique to avoid epistaxis." + }, + { + "label": "Clinical Pearl", + "value": "If patients point the spray directly up the middle of their nose, the steroid hits the nasal septum, thinning the blood vessels and causing severe, chronic nosebleeds. Instruct them to point the nozzle OUTWARDS toward the ear (the lateral turbinates) to prevent bleeding and maximize absorption." + } + ] + }, + { + "slug": "montelukast", + "name": "Montelukast", + "class": "Respiratory", + "subclass": "Leukotriene Receptor Antagonist", + "category": "Respiratory - Asthma & COPD", + "accent": "#475569", + "tag": "LTRA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3-5 h", + "cls": "", + "flag": "" + }, + { + "label": "Psych Risk", + "value": "BLACK BOX", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Freq", + "value": "NOCTE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Oral leukotriene receptor antagonist. An add-on therapy for asthma and allergic rhinitis, particularly effective in exercise-induced or aspirin-exacerbated asthma.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Black Box Warning for severe neuropsychiatric side effects (suicidality, nightmares, agitation), especially in children/adolescents.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Montelukast is a useful add-on for exercise-induced and allergic asthma, but carries an FDA black box warning for neuropsychiatric events including suicidality.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Neuropsychiatric events: agitation, aggressive behavior, dream abnormalities, hallucinations, depression, suicidal ideation.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Mild GI upset.", + "tags": [] + }, + { + "key": "Immunological", + "val": "RARE — Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Asthma (Adults)", + "val": "**PO** 10 mg **NOCTE**.", + "tags": [] + }, + { + "key": "Asthma (Children 6-14)", + "val": "**PO** 5 mg chewable tablet **NOCTE**.", + "tags": [] + }, + { + "key": "Asthma (Children 2-5)", + "val": "**PO** 4 mg chewable tablet **NOCTE**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Singulair, Lukair", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (10 mg). Chewable tablets (4 mg, 5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for chronic asthma.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prophylaxis and chronic treatment of asthma, symptomatic relief of seasonal allergic rhinitis.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Second- or third-line add-on to ICS. Exceptionally useful in patients whose asthma is heavily triggered by allergies, cold air, or NSAIDs.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Not for acute bronchospasm.", + "tags": [] + }, + { + "key": "Psychiatric", + "val": "CAUTION — History of severe depression or suicidal ideation.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Montelukast pregnancy row is informational/safe-use context and should not trigger a danger alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — Phenytoin and phenobarbital can induce CYP enzymes and reduce montelukast levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn parents/patients strictly to monitor for mood changes, horrific nightmares, or behavioral shifts within the first weeks of therapy.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Nighttime Dosing", + "val": "Should ideally be taken in the evening (NOCTE) to match the circadian rhythm of leukotriene release, which naturally peaks overnight and causes early-morning asthma symptoms.", + "tags": [] + }, + { + "key": "The NSAID Asthma Link", + "val": "Aspirin-Exacerbated Respiratory Disease (AERD) is caused by COX blockade shunting arachidonic acid entirely down the leukotriene pathway. Montelukast specifically blocks this, making it highly effective for these patients.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Highly specific antagonist of the cysteinyl leukotriene receptor (CysLT1). Blocks the action of leukotrienes released by mast cells/eosinophils, reducing airway oedema, smooth muscle contraction, and inflammation.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** Within hours to days.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-5 hours. Extensive hepatic metabolism (CYP3A4, CYP2C8).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: SINGULAIR/montelukast Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Leukotriene Receptor Antagonist — Oral leukotriene receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Tablets (10 mg). Chewable tablets (4 mg, 5 mg). (Singulair, Lukair)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10 mg **NOCTE**. Max **10 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Asthma (Adults): **PO** 10 mg **NOCTE**. Asthma (Children 6-14): **PO** 5 mg chewable tablet **NOCTE**. Asthma (Children 2-5): **PO** 4 mg chewable tablet **NOCTE**." + }, + { + "label": "Best Uses", + "value": "Montelukast is a useful add-on for exercise-induced and allergic asthma, but carries an FDA black box warning for neuropsychiatric events including suicidality." + }, + { + "label": "Avoid / Cautions", + "value": "Not for acute bronchospasm. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Neurological: Neuropsychiatric events: agitation, aggressive behavior, dream abnormalities, hallucinations, depression, suicidal ideation. Gastrointestinal: Mild GI upset. Immunological: RARE — Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis)." + }, + { + "label": "Key Interactions", + "value": "Phenytoin and phenobarbital can induce CYP enzymes and reduce montelukast levels." + }, + { + "label": "Monitoring", + "value": "Warn parents/patients strictly to monitor for mood changes, horrific nightmares, or behavioral shifts within the first weeks of therapy. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Should ideally be taken in the evening (NOCTE) to match the circadian rhythm of leukotriene release, which naturally peaks overnight and causes early-morning asthma symptoms." + } + ] + }, + { + "slug": "salbutamol", + "name": "Salbutamol", + "class": "Respiratory", + "subclass": "SABA", + "category": "Respiratory - Asthma & COPD", + "accent": "#475569", + "tag": "SABA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Variable", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "2–3 mins", + "cls": "", + "flag": "" + }, + { + "label": "Hypokalemia", + "value": "RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Tachycardia", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Short-Acting Beta-2 Agonist (SABA). The universal rescue bronchodilator for acute asthma and COPD exacerbations. Rapidly relieves bronchospasm.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max varies entirely by acuity. In severe acute asthma, can be given continuously via nebuliser.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "High doses drive potassium into cells, making it a highly effective emergency adjunct for treating severe hyperkalemia.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Salbutamol is the first-line reliever for acute bronchospasm in asthma and COPD, but overuse (>2 days/week) signals poor control requiring preventer therapy escalation.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "HIGH — Tachycardia, palpitations. MODERATE — Vasodilatory flushing.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Fine tremor (especially hands), anxiety, restlessness.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "MODERATE — Hypokalemia (transient), mild hyperglycemia, lactic acidosis with massive continuous doses.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Acute Asthma / COPD (MDI)", + "val": "**Inhaled** 4–12 puffs (100 mcg/puff) via spacer every 20 mins for first hour, then PRN.", + "tags": [] + }, + { + "key": "Severe Exacerbation (Neb)", + "val": "**Inhaled** 2.5–5 mg via nebuliser every 20 mins, or continuously in life-threatening cases.", + "tags": [] + }, + { + "key": "Hyperkalemia (Off-Label)", + "val": "**Inhaled** 10–20 mg via nebuliser STAT to rapidly shift K+ intracellularly.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Ventolin, Asmol", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Metered Dose Inhaler (100 mcg/actuation). Nebules (2.5 mg/2.5 mL, 5 mg/2.5 mL).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** infusion (ICU/Specialist only).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (MDI is S3 OTC, Nebules are S4).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Acute relief of bronchospasm in asthma and COPD, exercise-induced asthma.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Acute hyperkalemia (temporising measure).", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "The definitive first-line rescue inhaler. Not to be used as daily maintenance monotherapy in asthma.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Avoid IV use in risk of maternal hemorrhage (tocolytic effect).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "CAUTION — Use with care in severe ischemic heart disease or tachyarrhythmias (though hypoxia from asthma is often a greater risk).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A. Safe for acute relief.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Salbutamol pregnancy row is informational/safe-use context and should not trigger a danger alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Non-selective Beta-blockers (e.g., Propranolol) directly antagonise Salbutamol and can trigger fatal bronchospasm.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Additive hypokalemia if given with non-potassium sparing diuretics (e.g., Frusemide).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor **SpO2**, **RR**, and **HR**. Assess work of breathing. Symmetrical tachycardia is an expected physiological response.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — Check **U&E** (potassium) if administering massive repeated nebulised doses.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Spacer Rule", + "val": "MDI with a spacer is equally or MORE effective than a nebuliser for mild-to-moderate asthma, as nebulisers aerosolise the drug into the mouth/throat where it is swallowed and causes systemic tremor/tachycardia without helping the lungs.", + "tags": [] + }, + { + "key": "Lactic Acidosis Trap", + "val": "Continuous nebulised salbutamol stimulates glycogenolysis, raising lactate. Do not confuse this beta-2 driven 'Type B' lactic acidosis with hypoxic/septic 'Type A' lactic acidosis in a severe asthmatic.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selectively stimulates Beta-2 adrenoceptors in bronchial smooth muscle, activating adenyl cyclase and relaxing airways. Stimulates Na+/K+ ATPase, driving potassium into cells.", + "tags": [] + }, + { + "key": "Onset", + "val": "**Inhaled** 2-3 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "3-6 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "4-6 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: VENTOLIN/salbutamol Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "SABA — Short-Acting Beta-2 Agonist (SABA)." + }, + { + "label": "Route / Formulation", + "value": "Metered Dose Inhaler (100 mcg/actuation). Nebules (2.5 mg/2.5 mL, 5 mg/2.5 mL). (Ventolin, Asmol)" + }, + { + "label": "Usual Dose & Max", + "value": "**Inhaled** 4–12 puffs (100 mcg/puff) via spacer every 20 mins for first hour, then PRN. Max varies entirely by acuity. In severe acute asthma, can be given continuously via nebuliser." + }, + { + "label": "Key Indication Doses", + "value": "Acute Asthma / COPD (MDI): **Inhaled** 4–12 puffs (100 mcg/puff) via spacer every 20 mins for first hour, then PRN. Severe Exacerbation (Neb): **Inhaled** 2.5–5 mg via nebuliser every 20 mins, or continuously in life-threatening cases. Hyperkalemia (Off-Label): **Inhaled** 10–20 mg via nebuliser STAT to rapidly shift K+ intracellularly." + }, + { + "label": "Best Uses", + "value": "Salbutamol is the first-line reliever for acute bronchospasm in asthma and COPD, but overuse (>2 days/week) signals poor control requiring preventer therapy escalation." + }, + { + "label": "Avoid / Cautions", + "value": "Avoid IV use in risk of maternal hemorrhage (tocolytic effect). **Pregnancy** Category A. Safe for acute relief." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Tachycardia, palpitations. MODERATE — Vasodilatory flushing. Neurological: Fine tremor (especially hands), anxiety, restlessness. Metabolic: Hypokalemia (transient), mild hyperglycemia, lactic acidosis with massive continuous doses." + }, + { + "label": "Key Interactions", + "value": "Non-selective Beta-blockers (e.g., Propranolol) directly antagonise Salbutamol and can trigger fatal bronchospasm. Additive hypokalemia if given with non-potassium sparing diuretics (e.g., Frusemide)." + }, + { + "label": "Monitoring", + "value": "Monitor **SpO2**, **RR**, and **HR**. Assess work of breathing. Symmetrical tachycardia is an expected physiological response. Check **U&E** (potassium) if administering massive repeated nebulised doses." + }, + { + "label": "Clinical Pearl", + "value": "MDI with a spacer is equally or MORE effective than a nebuliser for mild-to-moderate asthma, as nebulisers aerosolise the drug into the mouth/throat where it is swallowed and causes systemic tremor/tachycardia without helping the lungs." + } + ] + }, + { + "slug": "tiotropium", + "name": "Tiotropium", + "class": "Respiratory", + "subclass": "LAMA", + "category": "Respiratory - Asthma & COPD", + "accent": "#475569", + "tag": "LAMA", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "18 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5-6 Days", + "cls": "", + "flag": "" + }, + { + "label": "Freq", + "value": "ONCE DAILY", + "cls": "good", + "flag": "" + }, + { + "label": "Dry Mouth", + "value": "COMMON", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Long-Acting Muscarinic Antagonist (LAMA). The gold-standard baseline maintenance bronchodilator for COPD.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **18 mcg/day** (HandiHaler) or **5 mcg/day** (Respimat).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never use for acute bronchospasm. Prevent patients from accidentally swallowing the HandiHaler capsules.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Tiotropium is the gold-standard long-acting anticholinergic for COPD maintenance and severe asthma add-on, but provides no acute relief and must not be used as a rescue inhaler.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Dry mouth (usually mild but persistent), constipation.", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "MODERATE — Urinary retention in susceptible patients (BPH).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Mild tachycardia, rare arrhythmias.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "COPD Maintenance", + "val": "**Inhaled** 18 mcg **OD** (inhale contents of 1 capsule via HandiHaler) OR 2 puffs (2.5 mcg/puff) **OD** via Respimat.", + "tags": [] + }, + { + "key": "Asthma Maintenance", + "val": "**Inhaled** 2 puffs (2.5 mcg/puff) **OD** via Respimat (add-on to ICS/LABA).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Spiriva HandiHaler, Spiriva Respimat", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Dry powder capsules for inhalation (18 mcg). Soft mist inhaler (2.5 mcg/puff).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for COPD.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Maintenance treatment of COPD, add-on maintenance for severe asthma.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line monotherapy for symptomatic COPD. Significantly reduces COPD exacerbations and hospitalisations.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Do not use for acute bronchospasm relief.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CAUTION — Predominantly renally excreted; monitor closely in moderate-to-severe renal impairment (**CrCl** ≤ 50).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "monitor", + "severity": "caution", + "match": { + "crcl": { + "lte": 50 + } + }, + "note": "Tiotropium renal impairment should prompt monitoring for anticholinergic toxicity rather than automatic contraindication." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Tiotropium pregnancy row should prompt benefit-risk review rather than automatic contraindication." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "MODERATE — Additive effects with other anticholinergics (e.g., Oxybutynin, Amitriptyline). Avoid concurrent use with Ipratropium.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Check inhaler technique regularly. Monitor for severe dry mouth leading to dental caries.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Swallowing Trap", + "val": "Ward patients routinely mistake the HandiHaler capsules for oral medications and swallow them. They must be pierced and inhaled. This is a massive cause of treatment failure.", + "tags": [] + }, + { + "key": "LAMA over LABA", + "val": "In COPD, LAMAs (like Tiotropium) generally outperform LABAs in reducing exacerbation rates. They are the backbone of therapy.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Binds to M3 muscarinic receptors in the airways, causing prolonged bronchodilation. Dissociates extremely slowly from M3, providing 24-hour coverage.", + "tags": [] + }, + { + "key": "Onset", + "val": "**Inhaled** 30 mins. Max effect takes up to 4 weeks of daily use.", + "tags": [] + }, + { + "key": "Duration", + "val": "> 24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5-6 Days (Allows true once-daily dosing).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: SPIRIVA/tiotropium Australian PI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "LAMA — Long-Acting Muscarinic Antagonist (LAMA)." + }, + { + "label": "Route / Formulation", + "value": "Dry powder capsules for inhalation (18 mcg). Soft mist inhaler (2.5 mcg/puff). (Spiriva HandiHaler, Spiriva Respimat)" + }, + { + "label": "Usual Dose & Max", + "value": "**Inhaled** 18 mcg **OD** (inhale contents of 1 capsule via HandiHaler) OR 2 puffs (2.5 mcg/puff) **OD** via Respimat. Max **18 mcg/day** (HandiHaler) or **5 mcg/day** (Respimat)." + }, + { + "label": "Key Indication Doses", + "value": "COPD Maintenance: **Inhaled** 18 mcg **OD** (inhale contents of 1 capsule via HandiHaler) OR 2 puffs (2.5 mcg/puff) **OD** via Respimat. Asthma Maintenance: **Inhaled** 2 puffs (2.5 mcg/puff) **OD** via Respimat (add-on to ICS/LABA)." + }, + { + "label": "Best Uses", + "value": "Tiotropium is the gold-standard long-acting anticholinergic for COPD maintenance and severe asthma add-on, but provides no acute relief and must not be used as a rescue inhaler." + }, + { + "label": "Avoid / Cautions", + "value": "Do not use for acute bronchospasm relief. **Pregnancy** Category B1." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Dry mouth (usually mild but persistent), constipation. Genitourinary: Urinary retention in susceptible patients (BPH). Cardiovascular: Mild tachycardia, rare arrhythmias." + }, + { + "label": "Key Interactions", + "value": "Additive effects with other anticholinergics (e.g., Oxybutynin, Amitriptyline). Avoid concurrent use with Ipratropium." + }, + { + "label": "Monitoring", + "value": "Check inhaler technique regularly. Monitor for severe dry mouth leading to dental caries. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Ward patients routinely mistake the HandiHaler capsules for oral medications and swallow them. They must be pierced and inhaled. This is a massive cause of treatment failure." + } + ] + }, + { + "slug": "acetylcysteine", + "name": "Acetylcysteine", + "class": "Antidote", + "subclass": "Glutathione Precursor", + "category": "Toxicology & Antidotes", + "accent": "#e11d48", + "tag": "ANTIDOTE", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "Weight Based", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5.6 h", + "cls": "", + "flag": "" + }, + { + "label": "Anaphylactoid", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Route", + "value": "IV or PO", + "cls": "purple", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The definitive, life-saving antidote for Paracetamol (Acetaminophen) overdose. Replenishes hepatic glutathione to neutralize the toxic NAPQI metabolite.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Weight-based nomogram (Standard 2-bag or 3-bag protocol). Max weight used for calculations is usually 110 kg.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be started within 8 hours of ingestion for 100% efficacy against hepatotoxicity. Delays are fatal.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Acetylcysteine is the life-saving antidote for paracetamol overdose when given within the treatment window, but the IV infusion commonly causes anaphylactoid reactions requiring rate adjustment.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Immunological", + "val": "HIGH — Non-IgE Anaphylactoid reactions (Flushing, rash, wheeze, hypotension). Most common during the first fast infusion bag.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe nausea and vomiting (can complicate PO administration).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Paracetamol Overdose (2-Bag IV Protocol)", + "val": "**IV** Bag 1: 200 mg/kg over 4 hours. Bag 2: 100 mg/kg over 16 hours. (Total 300 mg/kg over 20 hours).", + "tags": [] + }, + { + "key": "Contrast Nephropathy Prophylaxis", + "val": "**PO** 600 mg **BD** the day before and day of contrast (Off-label, evidence is highly debated).", + "tags": [] + }, + { + "key": "Mucolytic (CF/Bronchiectasis)", + "val": "**Inhaled** via nebuliser (Off-label).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Parvolex (IV)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (2 g/10 mL) for **IV** infusion. Highly concentrated, must be diluted in D5W or Normal Saline.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Paracetamol overdose.", + "tags": ["TGA"] + }, + { + "key": "Off-Label", + "val": "Prevention of contrast-induced nephropathy, fulminant hepatic failure (non-paracetamol).", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "Mandatory ED/ICU protocol drug. Plotted against the Rumack-Matthew nomogram.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "NONE — In the context of a toxic paracetamol overdose, there are zero absolute contraindications to NAC.", + "tags": [] + }, + { + "key": "Asthma", + "val": "CAUTION — Asthmatics have a higher risk of severe bronchospasm during the anaphylactoid reaction.", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — No major systemic interactions. However, it is chemically incompatible in the same IV line with many drugs (e.g., penicillins). Run on a dedicated line.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Baseline and end-of-infusion **LFTs** (ALT/AST), **U&E**, **INR**, and Paracetamol levels.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Monitor closely during Bag 1 for anaphylactoid reactions. If flushing/wheeze occurs, stop infusion, give antihistamines, and restart at a slower rate once resolved.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Rash Reaction", + "val": "The classic 'NAC Rash' is an anaphylactoid (rate-related histamine release), not a true IgE anaphylaxis. You do not need to abandon the drug. Slow the rate, treat the histamine, and push through. The liver needs the antidote.", + "tags": [] + }, + { + "key": "Smells Like Eggs", + "val": "The IV solution contains intense sulfur groups and smells strongly of rotten eggs. Warn the patient so they don't think it has gone bad.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Paracetamol overdose depletes glutathione, allowing the toxic metabolite NAPQI to destroy liver cells. Acetylcysteine acts as a glutathione substitute, binding and neutralizing NAPQI. Also acts as a systemic antioxidant.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5.6 hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - ACETYLCYSTEINE-LINK ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Glutathione Precursor — The definitive, life-saving antidote for Paracetamol (Acetaminophen) overdose." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (2 g/10 mL) for **IV** infusion. Highly concentrated, must be diluted in D5W or Normal Saline. (Parvolex (IV))" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** Bag 1: 200 mg/kg over 4 hours. Bag 2: 100 mg/kg over 16 hours. (Total 300 mg/kg over 20 hours). Weight-based nomogram (Standard 2-bag or 3-bag protocol). Max weight used for calculations is usually 110 kg." + }, + { + "label": "Key Indication Doses", + "value": "Paracetamol Overdose (2-Bag IV Protocol): **IV** Bag 1: 200 mg/kg over 4 hours. Bag 2: 100 mg/kg over 16 hours. (Total 300 mg/kg over 20 hours). Contrast Nephropathy Prophylaxis: **PO** 600 mg **BD** the day before and day of contrast (Off-label, evidence is highly debated). Mucolytic (CF/Bronchiectasis): **Inhaled** via nebuliser (Off-label)." + }, + { + "label": "Best Uses", + "value": "Acetylcysteine is the life-saving antidote for paracetamol overdose when given within the treatment window, but the IV infusion commonly causes anaphylactoid reactions requiring rate adjustment." + }, + { + "label": "Avoid / Cautions", + "value": "NONE — In the context of a toxic paracetamol overdose, there are zero absolute contraindications to NAC." + }, + { + "label": "Key Risks", + "value": "Immunological: Non-IgE Anaphylactoid reactions (Flushing, rash, wheeze, hypotension). Most common during the first fast infusion bag. Gastrointestinal: Severe nausea and vomiting (can complicate PO administration)." + }, + { + "label": "Key Interactions", + "value": "No major systemic interactions. However, it is chemically incompatible in the same IV line with many drugs (e.g., penicillins). Run on a dedicated line." + }, + { + "label": "Monitoring", + "value": "Baseline and end-of-infusion **LFTs** (ALT/AST), **U&E**, **INR**, and Paracetamol levels. Monitor closely during Bag 1 for anaphylactoid reactions. If flushing/wheeze occurs, stop infusion, give antihistamines, and restart at a slower rate once resolved." + }, + { + "label": "Clinical Pearl", + "value": "The classic 'NAC Rash' is an anaphylactoid (rate-related histamine release), not a true IgE anaphylaxis. You do not need to abandon the drug. Slow the rate, treat the histamine, and push through. The liver needs the antidote." + } + ] + }, + { + "slug": "flumazenil", + "name": "Flumazenil", + "class": "Antidote", + "subclass": "GABA-A Antagonist", + "category": "Toxicology & Antidotes", + "accent": "#e11d48", + "tag": "REVERSAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "2 mg (STAT)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "40–80 mins", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Seizure Risk", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Resedation", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Competitive benzodiazepine receptor antagonist. Rapidly reverses benzodiazepine-induced sedation and respiratory depression.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2 mg** per acute reversal event.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Do NOT use in mixed overdoses or chronic benzo users. Stripping benzos off the receptor in a dependent patient will trigger uncontrollable, fatal status epilepticus.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Flumazenil is the specific benzodiazepine antagonist for reversal of BZD sedation and overdose, but can precipitate seizures in chronic benzodiazepine users and has a shorter half-life than most BZDs.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Intractable seizures, severe acute benzodiazepine withdrawal syndrome (agitation, confusion, tachycardia).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "MODERATE — Arrhythmias (if combined with proarrhythmic drugs in a mixed overdose).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Iatrogenic Reversal (e.g. post-procedure)", + "val": "**IV** 200 mcg over 15 seconds. If no response in 60s, give 100 mcg every 60s. Max 1 mg.", + "tags": [] + }, + { + "key": "Overdose Reversal", + "val": "**IV** 200 mcg. If no response, 300 mcg. If no response, 500 mcg. Max 2 mg. (Strictly in ICU/ED with airway support ready).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Anexate", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (500 mcg/5 mL) for **IV** use only.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply. Restricted.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Reversal of conscious sedation (iatrogenic), pure benzodiazepine overdose in non-habituated patients.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly restricted in ED toxicology. Mostly used by anesthetists to wake patients up post-endoscopy.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known seizure disorder, chronic benzodiazepine use, mixed overdose with proconvulsant drugs (TCAs, Bupropion, Venlafaxine).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Flumazenil pregnancy row is Category B3/caution, not an automatic contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — TCAs. If a patient overdosed on a TCA and a Benzo, the Benzo is protecting their brain from the TCA-induced seizures. Giving Flumazenil removes the shield, causing immediate, often fatal seizures.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Continuous **SpO2**, **RR**, and **ECG**. The patient MUST be monitored for at least 2 hours post-reversal due to the risk of re-sedation.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "ABG if hypoxic/hypercapnic.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Re-sedation Trap", + "val": "Flumazenil wears off in 45 minutes. Diazepam lasts for 40 hours. The patient will wake up, talk to you, and then stop breathing an hour later when the Flumazenil washes out. You must observe them closely.", + "tags": [] + }, + { + "key": "Intubation is Safer", + "val": "In modern toxicology, we almost never give Flumazenil for a ward/street overdose. It is safer to simply intubate and ventilate the patient until the benzo wears off than to risk untreatable seizures.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitively inhibits the activity of benzodiazepines and Z-drugs at the GABA-A receptor complex.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 1-2 minutes.", + "tags": [] + }, + { + "key": "Duration", + "val": "30-60 mins (Much shorter than the half-life of most benzos!).", + "tags": [] + }, + { + "key": "Half-life", + "val": "40-80 minutes.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - FLUMAZENIL KABI ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "GABA-A Antagonist — Competitive benzodiazepine receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (500 mcg/5 mL) for **IV** use only. (Anexate)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 200 mcg over 15 seconds. If no response in 60s, give 100 mcg every 60s. Max 1 mg." + }, + { + "label": "Key Indication Doses", + "value": "Iatrogenic Reversal (e.g. post-procedure): **IV** 200 mcg over 15 seconds. If no response in 60s, give 100 mcg every 60s. Max 1 mg. Overdose Reversal: **IV** 200 mcg. If no response, 300 mcg. If no response, 500 mcg. Max 2 mg. (Strictly in ICU/ED with airway support ready)." + }, + { + "label": "Best Uses", + "value": "Flumazenil is the specific benzodiazepine antagonist for reversal of BZD sedation and overdose, but can precipitate seizures in chronic benzodiazepine users and has a shorter half-life than most BZDs." + }, + { + "label": "Avoid / Cautions", + "value": "Known seizure disorder, chronic benzodiazepine use, mixed overdose with proconvulsant drugs (TCAs, Bupropion, Venlafaxine). **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Neurological: Intractable seizures, severe acute benzodiazepine withdrawal syndrome (agitation, confusion, tachycardia). Cardiovascular: Arrhythmias (if combined with proarrhythmic drugs in a mixed overdose)." + }, + { + "label": "Key Interactions", + "value": "TCAs. If a patient overdosed on a TCA and a Benzo, the Benzo is protecting their brain from the TCA-induced seizures. Giving Flumazenil removes the shield, causing immediate, often fatal seizures." + }, + { + "label": "Monitoring", + "value": "Continuous **SpO2**, **RR**, and **ECG**. The patient MUST be monitored for at least 2 hours post-reversal due to the risk of re-sedation. ABG if hypoxic/hypercapnic." + }, + { + "label": "Clinical Pearl", + "value": "Flumazenil wears off in 45 minutes. Diazepam lasts for 40 hours. The patient will wake up, talk to you, and then stop breathing an hour later when the Flumazenil washes out. You must observe them closely." + } + ] + }, + { + "slug": "naloxone", + "name": "Naloxone", + "class": "Antidote", + "subclass": "Opioid Antagonist", + "category": "Toxicology & Antidotes", + "accent": "#e11d48", + "tag": "REVERSAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg (STAT)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "1 h (Short!)", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Resedation", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Route", + "value": "IV / IM / IN", + "cls": "purple", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Pure competitive mu-opioid receptor antagonist. Rapidly reverses opioid-induced respiratory depression and coma.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated to effect. If 10 mg total is given with no response, the coma is NOT caused by opioids.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Has a much shorter half-life than most opioids. The patient WILL re-sedate and stop breathing an hour later. Must observe closely.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Naloxone is the essential opioid antagonist for reversal of life-threatening respiratory depression, but has a shorter half-life than most opioids requiring repeated dosing and observation.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Acute, violent opioid withdrawal (agitation, aggression, vomiting, extreme pain, seizures).", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Tachycardia, severe hypertension, acute pulmonary oedema (from massive sympathetic surge upon waking).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Opioid Arrest / Apnoea", + "val": "**IV** / **IM** 400 mcg STAT. Repeat every 2-3 mins until breathing returns.", + "tags": [] + }, + { + "key": "Iatrogenic Sedation (Ward)", + "val": "**IV** 20-40 mcg (Micro-dosing). Repeat every 2 mins. (Goal is to restore breathing without causing agonizing withdrawal pain).", + "tags": [] + }, + { + "key": "Community Overdose", + "val": "**Intranasal** (Nyxoid) 1.8 mg spray into one nostril.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Prenoxad (IM), Nyxoid (Intranasal)", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (400 mcg/1 mL) for **IV** / **IM** / **SC**. Intranasal spray.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Pharmacy Medicine (S3) for take-home naloxone. Hospital supply for ampoules.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Opioid overdose, reversal of intra-operative opioid sedation.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "The definitive opioid antidote. Can be given by laypeople via nasal spray in the community.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "NONE — No absolute contraindications in life-threatening respiratory depression.", + "tags": [] + }, + { + "key": "Chronic Pain", + "val": "CAUTION — Stripping opioids off a chronic pain patient will cause excruciating, difficult-to-treat pain. Micro-dose (20mcg) if they are just drowsy but still breathing.", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Buprenorphine (Suboxone). Buprenorphine binds so tightly to the receptor that standard doses of Naloxone cannot displace it. Massive doses (or continuous infusions) are required.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Continuous **SpO2** and **RR**. The patient must be observed for at least 2-4 hours post-administration (or longer for sustained-release opioids) to catch re-sedation.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Methadone Trap", + "val": "Methadone lasts for 40 hours. Naloxone lasts for 1 hour. If you reverse a methadone overdose, you MUST set up a continuous IV Naloxone infusion (e.g., 2/3 of the wake-up dose per hour), or they will die when you turn your back.", + "tags": [] + }, + { + "key": "Titrate to RR, not GCS", + "val": "Your goal on the ward is a Respiratory Rate > 12. Your goal is NOT to have the patient wide awake. If they are sleeping but breathing normally, leave them alone to avoid causing withdrawal.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Highest affinity for the mu-opioid receptor. Competitively displaces opioid molecules from the receptor, instantly reversing CNS and respiratory depression.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** 1-2 mins. **IM** / **IN** 2-5 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "45-90 mins.", + "tags": [] + }, + { + "key": "Half-life", + "val": "1-1.5 hours (Rapidly cleared by the liver).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source Check - NARCAN/NYXOID ARTG/PI and PBS search checked 2026-05-13 for high-risk opioid/general batch appraisal: identity/access, indication, dosing, contraindications/populations, interactions, monitoring, pregnancy/lactation, patient-context metadata, and source-row status." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Opioid Antagonist — Pure competitive mu-opioid receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (400 mcg/1 mL) for **IV** / **IM** / **SC**. Intranasal spray. (Prenoxad (IM), Nyxoid (Intranasal))" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** / **IM** 400 mcg STAT. Repeat every 2-3 mins until breathing returns. Titrated to effect. If 10 mg total is given with no response, the coma is NOT caused by opioids." + }, + { + "label": "Key Indication Doses", + "value": "Opioid Arrest / Apnoea: **IV** / **IM** 400 mcg STAT. Repeat every 2-3 mins until breathing returns. Iatrogenic Sedation (Ward): **IV** 20-40 mcg (Micro-dosing). Repeat every 2 mins. (Goal is to restore breathing without causing agonizing withdrawal pain). Community Overdose: **Intranasal** (Nyxoid) 1.8 mg spray into one nostril." + }, + { + "label": "Best Uses", + "value": "Naloxone is the essential opioid antagonist for reversal of life-threatening respiratory depression, but has a shorter half-life than most opioids requiring repeated dosing and observation." + }, + { + "label": "Avoid / Cautions", + "value": "NONE — No absolute contraindications in life-threatening respiratory depression." + }, + { + "label": "Key Risks", + "value": "Neurological: Acute, violent opioid withdrawal (agitation, aggression, vomiting, extreme pain, seizures). Cardiovascular: Tachycardia, severe hypertension, acute pulmonary oedema (from massive sympathetic surge upon waking)." + }, + { + "label": "Key Interactions", + "value": "Buprenorphine (Suboxone). Buprenorphine binds so tightly to the receptor that standard doses of Naloxone cannot displace it. Massive doses (or continuous infusions) are required." + }, + { + "label": "Monitoring", + "value": "Continuous **SpO2** and **RR**. The patient must be observed for at least 2-4 hours post-administration (or longer for sustained-release opioids) to catch re-sedation." + }, + { + "label": "Clinical Pearl", + "value": "Methadone lasts for 40 hours. Naloxone lasts for 1 hour. If you reverse a methadone overdose, you MUST set up a continuous IV Naloxone infusion (e.g., 2/3 of the wake-up dose per hour), or they will die when you turn your back." + } + ] + }, + { + "slug": "dutasteride", + "name": "Dutasteride", + "class": "Urology", + "subclass": "5-Alpha Reductase Inhibitor", + "category": "Urology", + "accent": "#475569", + "tag": "5-ARI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "500 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "5 WEEKS", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Teratogenic", + "value": "CATEGORY X", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Onset", + "value": "3-6 MONTHS", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Dual 5-Alpha Reductase Inhibitor. More potent than Finasteride, blocking both Type I and Type II enzymes. Profoundly drops DHT levels.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **500 mcg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Has a massive 5-week half-life. Patients cannot donate blood for 6 months after stopping due to teratogenic risk to pregnant recipients.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Dutasteride is a more potent dual 5-alpha reductase inhibitor than finasteride for BPH, but has a very long half-life (5 weeks) and the same sexual side-effect profile.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine/GU", + "val": "HIGH — Impotence, decreased libido, ejaculation disorders.", + "tags": [] + }, + { + "key": "Endocrine", + "val": "MODERATE — Gynecomastia, breast tenderness/enlargement.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Mildly increased risk of heart failure (rare).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Benign Prostatic Hyperplasia", + "val": "**PO** 500 mcg **OD** (Swallow whole, do not chew or open capsules).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Avodart, Duodart (combo with Tamsulosin)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Soft gelatin capsules (500 mcg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "BPH to reduce symptom progression and surgical risk.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Often preferred over finasteride as combo therapy (Duodart) for aggressive BPH management.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Women, children, and adolescents. Pregnant women MUST NOT handle leaking capsules because dutasteride can be absorbed through skin and may harm a male fetus.", + "tags": [], + "patient": { + "factors": ["pregnancy", "paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Dutasteride is contraindicated in pregnancy risk contexts and should not be used in children/adolescents." + } + }, + { + "key": "Hepatic Impairment", + "val": "CAUTION — Extensively hepatically metabolised; use caution in hepatic disease and avoid unsupervised use in severe **Hepatic** impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "caution", + "severity": "caution", + "match": { + "hepatic": ["moderate", "severe"] + }, + "note": "Dutasteride is extensively hepatically metabolised and needs review in hepatic impairment." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP3A4** inhibitors (e.g., Ritonavir, Ketoconazole) can significantly increase dutasteride blood levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Like finasteride, Dutasteride artificially halves serum PSA. Double the PSA result for cancer screening.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Blood Donation Ban", + "val": "Because the half-life is 5 weeks, the drug stays in the blood for months. Patients are strictly banned from donating blood for 6 months after cessation to prevent the blood going to a pregnant woman and causing birth defects.", + "tags": [] + }, + { + "key": "Capsule Warning", + "val": "The contents of the soft gel capsule can be absorbed directly through the skin. If a capsule breaks on the ward, it must be handled with gloves.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits both Type I and Type II 5-alpha-reductase, suppressing >90% of circulating DHT (compared to ~70% for Finasteride).", + "tags": [] + }, + { + "key": "Onset", + "val": "3-6 MONTHS for peak symptomatic benefit.", + "tags": [] + }, + { + "key": "Half-life", + "val": "5 WEEKS (Highly lipophilic, massive volume of distribution).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: AVODART/dutasteride Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "5-Alpha Reductase Inhibitor — Dual 5-Alpha Reductase Inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Soft gelatin capsules (500 mcg). (Avodart, Duodart (combo with Tamsulosin))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 500 mcg **OD** (Swallow whole, do not chew or open capsules). Max **500 mcg/day**." + }, + { + "label": "Best Uses", + "value": "Dutasteride is a more potent dual 5-alpha reductase inhibitor than finasteride for BPH, but has a very long half-life (5 weeks) and the same sexual side-effect profile." + }, + { + "label": "Avoid / Cautions", + "value": "Women, children. Pregnant women MUST NOT touch leaking capsules (Category X)." + }, + { + "label": "Key Risks", + "value": "Endocrine/GU: Impotence, decreased libido, ejaculation disorders. Endocrine: Gynecomastia, breast tenderness/enlargement. Cardiovascular: Mildly increased risk of heart failure (rare)." + }, + { + "label": "Key Interactions", + "value": "**CYP3A4** inhibitors (e.g., Ritonavir, Ketoconazole) can significantly increase dutasteride blood levels." + }, + { + "label": "Monitoring", + "value": "Like finasteride, Dutasteride artificially halves serum PSA. Double the PSA result for cancer screening." + }, + { + "label": "Clinical Pearl", + "value": "Because the half-life is 5 weeks, the drug stays in the blood for months. Patients are strictly banned from donating blood for 6 months after cessation to prevent the blood going to a pregnant woman and causing birth defects." + } + ] + }, + { + "slug": "finasteride", + "name": "Finasteride", + "class": "Urology", + "subclass": "5-Alpha Reductase Inhibitor", + "category": "Urology", + "accent": "#475569", + "tag": "5-ARI", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "5 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "6 h", + "cls": "", + "flag": "" + }, + { + "label": "Teratogenic", + "value": "CATEGORY X", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Onset", + "value": "3-6 MONTHS", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "5-Alpha Reductase Inhibitor. Blocks the conversion of testosterone to DHT. Physically shrinks the prostate gland over time and halts male pattern baldness.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **5 mg/day** (for BPH) or **1 mg/day** (for alopecia).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly teratogenic. Pregnant women must not handle crushed or broken tablets.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Finasteride is a 5-alpha reductase inhibitor for BPH and male pattern baldness, but takes 3-6 months for effect and causes sexual dysfunction that may persist after discontinuation.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine/GU", + "val": "HIGH — Decreased libido, erectile dysfunction, decreased ejaculate volume (can persist even after stopping the drug).", + "tags": [] + }, + { + "key": "Endocrine", + "val": "MODERATE — Gynecomastia, breast tenderness.", + "tags": [] + }, + { + "key": "Psychiatric", + "val": "MODERATE — Depression, anxiety (Post-finasteride syndrome).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Benign Prostatic Hyperplasia", + "val": "**PO** 5 mg **OD**.", + "tags": [] + }, + { + "key": "Androgenetic Alopecia", + "val": "**PO** 1 mg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Proscar (5 mg), Propecia (1 mg)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (1 mg, 5 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS) for BPH.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "BPH to reduce acute urinary retention and need for surgery. Male pattern baldness.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Disease-modifying agent for BPH. Used when the prostate is significantly enlarged (>40g).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Not for use in women or children.", + "tags": [], + "patient": { + "factors": ["paediatric"], + "action": "contraindication", + "severity": "danger", + "match": { + "age": { + "lt": 18 + } + }, + "note": "Finasteride is not for use in children." + } + }, + { + "key": "Pregnancy", + "val": "ABSOLUTE — **Pregnancy** Category X. Pregnant women or those who may become pregnant must not handle crushed or broken tablets because of risk to a male fetus.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "Finasteride is Category X and pregnant patients must avoid exposure to crushed or broken tablets." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "LOW — No major clinically significant drug interactions.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Finasteride artificially halves serum PSA levels. You MUST double the reported PSA value to accurately screen for prostate cancer while a patient is on this drug.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The PSA Trap", + "val": "If a patient on Finasteride 5mg has a PSA of 3.0, their true PSA is 6.0. Failing to double the number leads to missed prostate cancers.", + "tags": [] + }, + { + "key": "The Patience Rule", + "val": "Tamsulosin works today. Finasteride works in 6 months. Never prescribe Finasteride alone for acute urinary retention symptoms; the patient will fail therapy long before it kicks in.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive inhibitor of Type II 5-alpha-reductase. Reduces serum and tissue levels of dihydrotestosterone (DHT), inducing apoptosis in prostate epithelial cells.", + "tags": [] + }, + { + "key": "Onset", + "val": "Very slow. Takes 3-6 MONTHS to physically shrink the prostate and relieve symptoms.", + "tags": [] + }, + { + "key": "Half-life", + "val": "6 hours (but biological effect lasts much longer). Extensively hepatically metabolised.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: PROSCAR/PROPECIA/finasteride Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "5-Alpha Reductase Inhibitor — 5-Alpha Reductase Inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (1 mg, 5 mg). (Proscar (5 mg), Propecia (1 mg))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5 mg **OD**. Max **5 mg/day** (for BPH) or **1 mg/day** (for alopecia)." + }, + { + "label": "Key Indication Doses", + "value": "Benign Prostatic Hyperplasia: **PO** 5 mg **OD**. Androgenetic Alopecia: **PO** 1 mg **OD**." + }, + { + "label": "Best Uses", + "value": "Finasteride is a 5-alpha reductase inhibitor for BPH and male pattern baldness, but takes 3-6 months for effect and causes sexual dysfunction that may persist after discontinuation." + }, + { + "label": "Avoid / Cautions", + "value": "Women, children. **Pregnancy** Category X. Extreme risk of feminizing male fetuses. Pregnant nurses/pharmacists must not handle crushed pills." + }, + { + "label": "Key Risks", + "value": "Endocrine/GU: Decreased libido, erectile dysfunction, decreased ejaculate volume (can persist even after stopping the drug). Endocrine: Gynecomastia, breast tenderness. Psychiatric: Depression, anxiety (Post-finasteride syndrome)." + }, + { + "label": "Key Interactions", + "value": "No major clinically significant drug interactions." + }, + { + "label": "Monitoring", + "value": "Finasteride artificially halves serum PSA levels. You MUST double the reported PSA value to accurately screen for prostate cancer while a patient is on this drug." + }, + { + "label": "Clinical Pearl", + "value": "If a patient on Finasteride 5mg has a PSA of 3.0, their true PSA is 6.0. Failing to double the number leads to missed prostate cancers." + } + ] + }, + { + "slug": "oxybutynin", + "name": "Oxybutynin", + "class": "Urology", + "subclass": "Anticholinergic", + "category": "Urology", + "accent": "#475569", + "tag": "ANTICHOLINERGIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "2-3 h", + "cls": "", + "flag": "" + }, + { + "label": "Anticholinergic", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Dry Mouth", + "value": "SEVERE", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent antimuscarinic agent. Highly effective at relaxing the detrusor muscle of the bladder, but notorious for severe, intolerable systemic anticholinergic side effects.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day** (Immediate release) or **30 mg/day** (Patch).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "High risk of severe cognitive impairment, delirium, and falls in the elderly. Highly lipophilic, crosses BBB easily.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Oxybutynin is an effective anticholinergic for overactive bladder and urinary incontinence, but has the highest anticholinergic burden of its class causing dry mouth, constipation, and cognitive impairment in elderly.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Severe dry mouth (causes poor compliance and dental decay), severe constipation.", + "tags": [] + }, + { + "key": "Neurological", + "val": "HIGH — Confusion, delirium, hallucinations, dizziness (especially in elderly).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Ocular", + "val": "HIGH — Blurred vision, dry eyes.", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "MODERATE — Urinary retention (can paralyze the bladder *too* much).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Overactive Bladder / Spasm", + "val": "**PO** 5 mg **BD** to **TDS**. Max 20 mg/day.", + "tags": [] + }, + { + "key": "Transdermal Patch", + "val": "Apply 1 patch (3.9 mg/day) **Topical** twice weekly.", + "tags": [] + }, + { + "key": "Elderly / Frail", + "val": "MANDATORY — Start at 2.5 mg **BD**. Monitor strictly for confusion.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Ditropan, Oxytrol (patch)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Transdermal patch.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Overactive bladder (OAB) with urge incontinence, neurogenic bladder.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Highly effective historically, but increasingly superseded by newer, bladder-selective agents (Solifenacin, Mirabegron) due to horrific side effects.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Angle-closure glaucoma/shallow anterior chamber, urinary retention, gastrointestinal obstruction or ileus, toxic megacolon, severe ulcerative colitis, and myasthenia gravis.", + "tags": [] + }, + { + "key": "Elderly & Dementia", + "val": "CRITICAL — Avoid or use only with strong justification in dementia/cognitive impairment; frail elderly patients need low starting dose and close monitoring for delirium, constipation, and retention.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "caution", + "severity": "danger", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Oxybutynin has high anticholinergic burden and can precipitate delirium, constipation, and urinary retention in older/frail patients." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B1/B3 varies by formulation/source; use only if clearly needed and specialist-reviewed.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Oxybutynin in pregnancy should prompt benefit-risk review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Additive anticholinergic burden with TCAs, antipsychotics, and antihistamines (leads to frank delirium and bowel impaction).", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Antagonises prokinetics like Metoclopramide.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Monitor bowel chart (constipation) and assess cognition daily in older adults. Perform bladder scans if retention is suspected.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Patch Workaround", + "val": "The severe dry mouth is actually caused by the primary liver metabolite of Oxybutynin. Using the transdermal patch avoids first-pass metabolism, radically reducing dry mouth while maintaining bladder efficacy.", + "tags": [] + }, + { + "key": "Dental Destruction", + "val": "Chronic dry mouth from Oxybutynin destroys the protective saliva barrier, leading to rampant dental caries. Counsel on oral hygiene and sugar-free gum.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive antagonist of muscarinic (M1, M2, M3) receptors. Also has direct smooth muscle relaxant properties. Paralyzes the detrusor muscle.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "6-10 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "2-3 hours (Extensive first-pass metabolism).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: DITROPAN/oxybutynin Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Anticholinergic — Potent antimuscarinic agent." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg). (Ditropan, Oxytrol (patch))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5 mg **BD** to **TDS**. Max 20 mg/day." + }, + { + "label": "Key Indication Doses", + "value": "Overactive Bladder / Spasm: **PO** 5 mg **BD** to **TDS**. Max 20 mg/day. Transdermal Patch: Apply 1 patch (3.9 mg/day) **Topical** twice weekly. Elderly / Frail: Start at 2.5 mg **BD**. Monitor strictly for confusion." + }, + { + "label": "Best Uses", + "value": "Oxybutynin is an effective anticholinergic for overactive bladder and urinary incontinence, but has the highest anticholinergic burden of its class causing dry mouth, constipation, and cognitive impairment in elderly." + }, + { + "label": "Avoid / Cautions", + "value": "Narrow-angle glaucoma, urinary retention, severe ulcerative colitis, myasthenia gravis. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe dry mouth (causes poor compliance and dental decay), severe constipation. Neurological: Confusion, delirium, hallucinations, dizziness (especially in elderly). Ocular: Blurred vision, dry eyes. Genitourinary: Urinary retention (can paralyze the bladder *too* much)." + }, + { + "label": "Key Interactions", + "value": "Additive anticholinergic burden with TCAs, antipsychotics, and antihistamines (leads to frank delirium and bowel impaction). Antagonises prokinetics like Metoclopramide." + }, + { + "label": "Monitoring", + "value": "Monitor bowel chart (constipation) and assess cognition daily in older adults. Perform bladder scans if retention is suspected." + }, + { + "label": "Clinical Pearl", + "value": "The severe dry mouth is actually caused by the primary liver metabolite of Oxybutynin. Using the transdermal patch avoids first-pass metabolism, radically reducing dry mouth while maintaining bladder efficacy." + } + ] + }, + { + "slug": "sildenafil", + "name": "Sildenafil", + "class": "Urology", + "subclass": "PDE5 Inhibitor", + "category": "Urology", + "accent": "#475569", + "tag": "PDE5 INHIBITOR", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "100 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "4 h", + "cls": "", + "flag": "" + }, + { + "label": "Nitrates", + "value": "FATAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Blue Vision", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Potent Phosphodiesterase-5 (PDE5) inhibitor. Enhances nitric oxide-mediated vasodilation in the corpus cavernosum and pulmonary vasculature.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **100 mg/day** (Erectile Dysfunction).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Absolutely contraindicated within 24 hours of ANY nitrate administration due to risk of refractory, fatal hypotension.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Sildenafil is the original PDE5 inhibitor for erectile dysfunction and pulmonary hypertension, but is absolutely contraindicated with nitrates due to fatal hypotension risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Severe hypotension (if interacting). MODERATE — Flushing, headache, nasal congestion.", + "tags": [] + }, + { + "key": "Ocular", + "val": "HIGH — Cyanopsia (blue-tinted vision). RARE — NAION (sudden permanent blindness).", + "tags": [] + }, + { + "key": "Genitourinary", + "val": "CRITICAL — Priapism (erection > 4 hours, medical emergency requiring aspiration/phenylephrine).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Erectile Dysfunction", + "val": "**PO** 50 mg approximately 1 hour before sexual activity. Max **100 mg/day**.", + "tags": [] + }, + { + "key": "Pulmonary Arterial HTN", + "val": "**PO** 20 mg **TDS** (Requires specialist initiation).", + "tags": [] + }, + { + "key": "Elderly / Renal / Hepatic", + "val": "MANDATORY — Start at 25 mg in older adults, severe renal impairment, or hepatic impairment; titrate only if tolerated.", + "tags": [], + "patient": { + "factors": ["elderly", "renal", "hepatic"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 30 + }, + "age": { + "gte": 65 + }, + "hepatic": ["mild", "moderate", "severe"] + }, + "note": "Sildenafil requires a lower starting dose in older adults and renal/hepatic impairment." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Viagra, Revatio (PAH)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (25 mg, 50 mg, 100 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** use (ICU for PAH only).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Private script (ED). Authority Required PBS for PAH.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Erectile dysfunction (ED), Pulmonary Arterial Hypertension (PAH).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Raynaud's phenomenon.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "First-line oral therapy for ED. Essential vasodilator in PAH.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent nitrates/nitric oxide donors, amyl nitrite/poppers, riociguat, high cardiovascular risk where sexual activity is inadvisable, or recent serious cardiovascular event.", + "tags": [] + }, + { + "key": "Ocular", + "val": "CRITICAL — History of Non-arteritic anterior ischemic optic neuropathy (NAION).", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Nitrates, nitric oxide donors, amyl nitrite/poppers, or riociguat can cause profound hypotension. Do not give nitrates within 24 hours of sildenafil.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Alpha-blockers (Prazosin, Tamsulosin). Space doses by at least 4 hours to prevent orthostatic collapse.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — **CYP3A4** inhibitors (Clarithromycin, Grapefruit juice) drastically increase Sildenafil levels. Max dose 25mg.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Warn patients to seek immediate ED care for chest pain, sudden vision loss, or erection > 4 hours.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The ED Protocol", + "val": "If a male patient presents to ED with crushing chest pain, you MUST ask if they have taken Viagra/Cialis before you administer GTN. Giving GTN will kill them if the PDE5i is still in their system.", + "tags": [] + }, + { + "key": "The Blue Pill", + "val": "Sildenafil mildly inhibits PDE6 in the retina, which processes color vision. This causes a harmless, temporary blue tint to their vision at high doses.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits PDE5, the enzyme that degrades cGMP. High cGMP levels cause smooth muscle relaxation and massive blood inflow to the penis and lungs.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-60 mins (Delayed by high-fat meals).", + "tags": [] + }, + { + "key": "Duration", + "val": "4-5 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "4 hours. Hepatically metabolised by CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: VIAGRA/sildenafil Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "PDE5 Inhibitor — Potent Phosphodiesterase-5 (PDE5) inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (25 mg, 50 mg, 100 mg). (Viagra, Revatio (PAH))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 50 mg approximately 1 hour before sexual activity. Max **100 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Erectile Dysfunction: **PO** 50 mg approximately 1 hour before sexual activity. Max **100 mg/day**. Pulmonary Arterial HTN: **PO** 20 mg **TDS** (Requires specialist initiation). Elderly / Renal / Hepatic: Start at 25 mg if **eGFR** < 30, severe hepatic impairment, or age > 65." + }, + { + "label": "Best Uses", + "value": "Sildenafil is the original PDE5 inhibitor for erectile dysfunction and pulmonary hypertension, but is absolutely contraindicated with nitrates due to fatal hypotension risk." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent use of ANY nitrates (GTN, isosorbide). High cardiovascular risk preventing sexual activity. Recent MI/Stroke." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Severe hypotension (if interacting). MODERATE — Flushing, headache, nasal congestion. Ocular: Cyanopsia (blue-tinted vision). RARE — NAION (sudden permanent blindness). Genitourinary: Priapism (erection > 4 hours, medical emergency requiring aspiration/phenylephrine)." + }, + { + "label": "Key Interactions", + "value": "Nitrates (GTN patch, spray, sublingual). Fatal hypotension. Must wait 24 hours after Sildenafil before giving a nitrate. Alpha-blockers (Prazosin, Tamsulosin). Space doses by at least 4 hours to prevent orthostatic collapse. **CYP3A4** inhibitors (Clarithromycin, Grapefruit juice) drastically increase Sildenafil levels. Max dose 25mg." + }, + { + "label": "Monitoring", + "value": "Warn patients to seek immediate ED care for chest pain, sudden vision loss, or erection > 4 hours. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "If a male patient presents to ED with crushing chest pain, you MUST ask if they have taken Viagra/Cialis before you administer GTN. Giving GTN will kill them if the PDE5i is still in their system." + } + ] + }, + { + "slug": "solifenacin", + "name": "Solifenacin", + "class": "Urology", + "subclass": "Anticholinergic", + "category": "Urology", + "accent": "#475569", + "tag": "ANTICHOLINERGIC", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "45-68 h", + "cls": "", + "flag": "" + }, + { + "label": "M3 Selective", + "value": "YES", + "cls": "good", + "flag": "" + }, + { + "label": "Renal Adj.", + "value": "DOSE RED.", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Modern, bladder-selective antimuscarinic. Substantially better tolerated than Oxybutynin due to high affinity for the M3 receptor subtype located in the detrusor muscle.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Provides excellent overactive bladder relief with a fraction of the dry mouth and cognitive side effects of older agents.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Solifenacin is a better-tolerated antimuscarinic for overactive bladder than oxybutynin, but still carries anticholinergic risk in elderly and is contraindicated in uncontrolled narrow-angle glaucoma.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "MODERATE — Dry mouth, constipation (both significantly less severe than Oxybutynin but still common).", + "tags": [] + }, + { + "key": "Ocular", + "val": "LOW — Blurred vision.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "LOW — Mild QTc prolongation (rarely clinically significant unless combined with other agents).", + "tags": [], + "patient": { + "factors": ["qtc"], + "action": "caution", + "severity": "caution", + "match": { + "qtc": { + "gte": 450 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Overactive Bladder", + "val": "**PO** 5 mg **OD**. May increase to Max **10 mg/day**.", + "tags": [] + }, + { + "key": "Renal / Hepatic Impairment", + "val": "MANDATORY — Max 5 mg/day if **eGFR** < 30 or in moderate hepatic impairment.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Vesicare", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg, 10 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Overactive bladder syndrome (urge incontinence, urgency, frequency).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Preferred first-line antimuscarinic for OAB due to OD dosing and superior tolerability profile.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Urinary retention, gastric retention, uncontrolled narrow-angle glaucoma, toxic megacolon, severe hepatic impairment, or severe renal impairment with a strong CYP3A4 inhibitor.", + "tags": [], + "patient": { + "factors": ["hepatic", "renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + }, + "hepatic": ["severe"] + }, + "note": "Solifenacin is contraindicated in severe hepatic impairment and in severe renal impairment when combined with strong CYP3A4 inhibitors." + } + }, + { + "key": "Pregnancy", + "val": "CAUTION — **Pregnancy** Category B3; use only if benefit justifies risk.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "Solifenacin pregnancy exposure should prompt benefit-risk review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Heavily metabolised by **CYP3A4**. Strong inhibitors (Ketoconazole, Ritonavir) mandate a maximum dose of 5 mg/day to prevent toxicity.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "MODERATE — Additive anticholinergic effects with TCAs/antipsychotics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Bladder scans if the patient complains of straining or feeling incomplete emptying. Monitor bowel charts.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **eGFR** and **LFTs** to ensure the 10 mg dose is safe.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Patience Rule", + "val": "Unlike Oxybutynin which works relatively quickly, Solifenacin takes up to 4 weeks to reach maximum efficacy. Do not escalate to 10 mg too early; give the 5 mg dose time to work.", + "tags": [] + }, + { + "key": "The Cognitive Win", + "val": "Because it is highly selective for M3 (bladder) and largely ignores M1 (brain), Solifenacin is significantly safer for elderly patients prone to delirium.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Competitive muscarinic receptor antagonist with high selectivity for M3 receptors over M1 (brain) and M2 (heart). Decreases detrusor pressure and increases bladder capacity.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days. Peak effect seen at 4 weeks.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "45-68 hours (Very long, allows true once-daily dosing).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: VESICARE/solifenacin Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Anticholinergic — Modern, bladder-selective antimuscarinic." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg, 10 mg). (Vesicare)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5 mg **OD**. May increase to Max **10 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Overactive Bladder: **PO** 5 mg **OD**. May increase to Max **10 mg/day**. Renal / Hepatic Impairment: Max 5 mg/day if **eGFR** < 30 or in moderate hepatic impairment." + }, + { + "label": "Best Uses", + "value": "Solifenacin is a better-tolerated antimuscarinic for overactive bladder than oxybutynin, but still carries anticholinergic risk in elderly and is contraindicated in uncontrolled narrow-angle glaucoma." + }, + { + "label": "Avoid / Cautions", + "value": "Urinary retention, uncontrolled narrow-angle glaucoma, toxic megacolon. **Pregnancy** Category B3." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Dry mouth, constipation (both significantly less severe than Oxybutynin but still common). Ocular: Blurred vision. Cardiovascular: Mild QTc prolongation (rarely clinically significant unless combined with other agents)." + }, + { + "label": "Key Interactions", + "value": "Heavily metabolised by **CYP3A4**. Strong inhibitors (Ketoconazole, Ritonavir) mandate a maximum dose of 5 mg/day to prevent toxicity. Additive anticholinergic effects with TCAs/antipsychotics." + }, + { + "label": "Monitoring", + "value": "Bladder scans if the patient complains of straining or feeling incomplete emptying. Monitor bowel charts. Check **eGFR** and **LFTs** to ensure the 10 mg dose is safe." + }, + { + "label": "Clinical Pearl", + "value": "Unlike Oxybutynin which works relatively quickly, Solifenacin takes up to 4 weeks to reach maximum efficacy. Do not escalate to 10 mg too early; give the 5 mg dose time to work." + } + ] + }, + { + "slug": "tadalafil", + "name": "Tadalafil", + "class": "Urology", + "subclass": "PDE5 Inhibitor", + "category": "Urology", + "accent": "#475569", + "tag": "PDE5 INHIBITOR", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "17.5 h", + "cls": "", + "flag": "" + }, + { + "label": "Duration", + "value": "36 HOURS", + "cls": "good", + "flag": "" + }, + { + "label": "Nitrates", + "value": "FATAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Ultra-long-acting PDE5 inhibitor. Dubbed 'The Weekend Pill' due to its massive 36-hour duration of action. Highly effective for BPH as well as ED.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **20 mg/day** (PRN use) or **5 mg/day** (Daily use).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Because of the 17.5 hour half-life, Nitrates are strictly contraindicated for a full 48 HOURS after the last Tadalafil dose.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Tadalafil is the long-acting PDE5 inhibitor offering up to 36 hours of effect for ED and daily dosing for BPH, but carries the same absolute nitrate contraindication as all PDE5 inhibitors.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "MODERATE — Flushing, hypotension.", + "tags": [] + }, + { + "key": "Musculoskeletal", + "val": "HIGH — Back pain, severe myalgia (unique to Tadalafil due to mild PDE11 inhibition in skeletal muscle).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Dyspepsia (relaxes lower esophageal sphincter).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Erectile Dysfunction (PRN)", + "val": "**PO** 10-20 mg at least 30 mins before sexual activity. Max 1 dose in 24h.", + "tags": [] + }, + { + "key": "ED / BPH (Daily dosing)", + "val": "**PO** 5 mg **OD** (Provides continuous steady-state levels).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "MANDATORY — Use caution if CrCl <50 mL/min. Avoid once-daily dosing in severe renal impairment; PRN dosing needs lower maximums and specialist review.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "crcl": { + "lt": 50 + } + }, + "note": "Tadalafil requires renal dose review; once-daily dosing is not recommended in severe renal impairment." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Cialis", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (5 mg, 10 mg, 20 mg). Food does NOT affect absorption.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Private script.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Erectile dysfunction, Benign Prostatic Hyperplasia (BPH LUTS).", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Preferred over Sildenafil when patients want spontaneity without planning a pill 1 hour before, or if they have concurrent BPH.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Concurrent nitrates/nitric oxide donors, amyl nitrite/poppers, riociguat, or cardiovascular status where sexual activity is inadvisable. Severe hepatic impairment requires careful specialist benefit-risk review, not routine daily dosing.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "caution", + "severity": "caution", + "match": { + "hepatic": ["severe"] + }, + "note": "Tadalafil severe hepatic impairment requires careful benefit-risk review; once-daily dosing is not recommended." + } + }, + { + "key": "Renal Impairment", + "val": "HIGH — Accumulates in CKD. Strict dose reductions required.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 60 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Nitrates, nitric oxide donors, amyl nitrite/poppers, or riociguat can cause profound hypotension. Avoid nitrates for at least 48 hours after tadalafil.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Alpha-blockers (Tamsulosin). Tadalafil 5mg daily is approved for BPH, but if the patient is already on Tamsulosin, the combo can cause severe orthostatic drops.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Check **BP**. Assess for severe back pain (can mimic renal colic but is a benign side effect).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The BPH Hack", + "val": "Tadalafil 5mg daily relaxes the prostate and bladder neck via nitric oxide pathways. It is a highly effective, official treatment for BPH LUTS, effectively treating two conditions (BPH + ED) with one pill.", + "tags": [] + }, + { + "key": "Food Immunity", + "val": "Unlike Sildenafil (where a steak dinner traps the drug in the stomach), Tadalafil absorption is completely unaffected by food or high fat.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inhibits PDE5. Highly selective (less PDE6 cross-reactivity than Sildenafil, so no blue vision).", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 30-120 mins.", + "tags": [] + }, + { + "key": "Duration", + "val": "36 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "17.5 hours. Metabolised by CYP3A4.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: CIALIS/tadalafil Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "PDE5 Inhibitor — Ultra-long-acting PDE5 inhibitor." + }, + { + "label": "Route / Formulation", + "value": "Tablets (5 mg, 10 mg, 20 mg). Food does NOT affect absorption. (Cialis)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 10-20 mg at least 30 mins before sexual activity. Max 1 dose in 24h." + }, + { + "label": "Key Indication Doses", + "value": "Erectile Dysfunction (PRN): **PO** 10-20 mg at least 30 mins before sexual activity. Max 1 dose in 24h. ED / BPH (Daily dosing): **PO** 5 mg **OD** (Provides continuous steady-state levels). Renal Impairment: Max 10 mg PRN if **eGFR** 30-50. Max 5 mg/day if **eGFR** < 30." + }, + { + "label": "Best Uses", + "value": "Tadalafil is the long-acting PDE5 inhibitor offering up to 36 hours of effect for ED and daily dosing for BPH, but carries the same absolute nitrate contraindication as all PDE5 inhibitors." + }, + { + "label": "Avoid / Cautions", + "value": "Concurrent nitrates. Recent MI/Stroke. Severe hepatic impairment." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Flushing, hypotension. Musculoskeletal: Back pain, severe myalgia (unique to Tadalafil due to mild PDE11 inhibition in skeletal muscle). Gastrointestinal: Dyspepsia (relaxes lower esophageal sphincter)." + }, + { + "label": "Key Interactions", + "value": "Nitrates. Must withhold GTN for 48 HOURS post-tadalafil. Alpha-blockers (Tamsulosin). Tadalafil 5mg daily is approved for BPH, but if the patient is already on Tamsulosin, the combo can cause severe orthostatic drops." + }, + { + "label": "Monitoring", + "value": "Check **BP**. Assess for severe back pain (can mimic renal colic but is a benign side effect)." + }, + { + "label": "Clinical Pearl", + "value": "Tadalafil 5mg daily relaxes the prostate and bladder neck via nitric oxide pathways. It is a highly effective, official treatment for BPH LUTS, effectively treating two conditions (BPH + ED) with one pill." + } + ] + }, + { + "slug": "tamsulosin", + "name": "Tamsulosin", + "class": "Urology", + "subclass": "Alpha-1 Antagonist", + "category": "Urology", + "accent": "#475569", + "tag": "ALPHA-1", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "400 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "10-15 h", + "cls": "", + "flag": "" + }, + { + "label": "Hypotension", + "value": "RISK", + "cls": "warn", + "flag": "" + }, + { + "label": "Floppy Iris", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Highly selective Alpha-1A receptor antagonist. Relaxes smooth muscle in the prostate and bladder neck, rapidly improving urinary flow in BPH.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mcg/day** for the prolonged-release product.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be flagged to ophthalmologists prior to cataract surgery due to Intraoperative Floppy Iris Syndrome (IFIS).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Tamsulosin is the first-line alpha-blocker for BPH symptom relief with prostate selectivity, but causes significant first-dose hypotension and must be flagged before cataract surgery (IFIS risk).", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "MODERATE — Orthostatic hypotension, dizziness, syncope (less than prazosin, but still prevalent in the elderly).", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Genitourinary", + "val": "HIGH — Retrograde/abnormal ejaculation (almost 30% of patients at 800mcg dose).", + "tags": [] + }, + { + "key": "Ocular", + "val": "CRITICAL — Intraoperative Floppy Iris Syndrome (IFIS) during cataract surgery.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Benign Prostatic Hyperplasia", + "val": "**PO** 400 mcg **OD** after breakfast or the first meal of the day. Swallow whole; do not crush or chew.", + "tags": [] + }, + { + "key": "Ureteric Stone Expulsion", + "val": "**PO** 400 mcg **OD** (Off-label to dilate ureter and pass kidney stones).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Flomaxtra, Duodart (combo with Dutasteride)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Modified-release tablets/capsules (400 mcg). Do not crush.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Authority Required (PBS).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Lower urinary tract symptoms (LUTS) associated with BPH.", + "tags": ["PBS", "TGA"] + }, + { + "key": "Off-Label", + "val": "Medical expulsive therapy for ureteric stones.", + "tags": ["OFF"] + }, + { + "key": "Clinical Place", + "val": "First-line agent for rapid relief of BPH symptoms. Works within days, unlike 5-ARIs which take months.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — History of orthostatic hypotension/syncope or hypersensitivity/angioedema to tamsulosin.", + "tags": [] + }, + { + "key": "Hepatic Impairment", + "val": "CAUTION — Do not use in severe **Hepatic** impairment.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Tamsulosin should not be used in severe hepatic impairment." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Concurrent use with PDE5 inhibitors (Sildenafil) or other antihypertensives increases orthostatic collapse risk.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Strong **CYP3A4** inhibitors (Clarithromycin, Ketoconazole) drastically spike tamsulosin levels.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Postural **BP** monitoring upon initiation. Counsel patient to stand slowly.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "No specific routine laboratory tests required.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Cataract Catastrophe", + "val": "Tamsulosin permanently alters the iris muscle. If a patient undergoes cataract surgery, the iris will billow out (IFIS), complicating the surgery and risking blindness. Always ask about upcoming eye surgery before starting.", + "tags": [] + }, + { + "key": "Combination Power", + "val": "Tamsulosin shrinks the *symptoms* (works in days), while Dutasteride shrinks the *prostate* (works in months). The combination (Duodart) is the gold standard for severe BPH.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Selectively antagonizes Alpha-1A receptors (which dominate the prostate) over Alpha-1B receptors (which dominate blood vessels), relaxing the prostate with less systemic BP drop than Prazosin.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** Days.", + "tags": [] + }, + { + "key": "Duration", + "val": "24 h.", + "tags": [] + }, + { + "key": "Half-life", + "val": "10-15 hours. Extensively metabolised by CYP3A4 and CYP2D6.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-11: FLOMAXTRA/tamsulosin Australian PI and CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Alpha-1 Antagonist — Highly selective Alpha-1A receptor antagonist." + }, + { + "label": "Route / Formulation", + "value": "Modified-release tablets/capsules (400 mcg). Do not crush. (Flomaxtra, Duodart (combo with Dutasteride))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 400 mcg **OD** after breakfast or the first meal of the day. Swallow whole; do not crush or chew. Max **400 mcg/day** for FLOMAXTRA prolonged-release tablets." + }, + { + "label": "Key Indication Doses", + "value": "Benign Prostatic Hyperplasia: **PO** 400 mcg **OD** (Take after the same meal each day). May increase to 800 mcg after 4 weeks if no response. Ureteric Stone Expulsion: **PO** 400 mcg **OD** (Off-label to dilate ureter and pass kidney stones)." + }, + { + "label": "Best Uses", + "value": "Tamsulosin is the first-line alpha-blocker for BPH symptom relief with prostate selectivity, but causes significant first-dose hypotension and must be flagged before cataract surgery (IFIS risk)." + }, + { + "label": "Avoid / Cautions", + "value": "History of orthostatic hypotension syncope." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Orthostatic hypotension, dizziness, syncope (less than prazosin, but still prevalent in the elderly). Genitourinary: Retrograde/abnormal ejaculation (almost 30% of patients at 800mcg dose). Ocular: Intraoperative Floppy Iris Syndrome (IFIS) during cataract surgery." + }, + { + "label": "Key Interactions", + "value": "Concurrent use with PDE5 inhibitors (Sildenafil) or other antihypertensives increases orthostatic collapse risk. Strong **CYP3A4** inhibitors (Clarithromycin, Ketoconazole) drastically spike tamsulosin levels." + }, + { + "label": "Monitoring", + "value": "Postural **BP** monitoring upon initiation. Counsel patient to stand slowly. No specific routine laboratory tests required." + }, + { + "label": "Clinical Pearl", + "value": "Tamsulosin permanently alters the iris muscle. If a patient undergoes cataract surgery, the iris will billow out (IFIS), complicating the surgery and risking blindness. Always ask about upcoming eye surgery before starting." + } + ] + }, + { + "slug": "ascorbic-acid", + "name": "Ascorbic Acid", + "class": "Vitamin", + "subclass": "Water-Soluble", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "VITAMIN", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Dose", + "value": "500 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "Hours", + "cls": "", + "flag": "" + }, + { + "label": "Urine pH", + "value": "ACIDIFIES", + "cls": "warn", + "flag": "" + }, + { + "label": "Iron Absorb", + "value": "ENHANCES", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Vitamin C. Essential water-soluble antioxidant. Crucial for collagen synthesis and tissue repair. Rapidly excreted in the urine when saturated.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2000 mg/day** (Higher doses just cause severe osmotic diarrhea).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Useful with oral iron and for deficiency states, but routine megadose vitamin C has limited evidence and increases gastrointestinal intolerance and oxalate-stone risk.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Ascorbic Acid is used for scurvy treatment and prevention and as an adjunct in iron absorption, but mega-doses increase oxalate kidney stone risk and provide no proven benefit for cold prevention.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Osmotic diarrhea, severe abdominal cramping, nausea (virtually guaranteed at doses > 2g/day).", + "tags": [] + }, + { + "key": "Renal", + "val": "MODERATE — Oxalate kidney stones. Vitamin C is metabolized to oxalate, and massive chronic doses increase the risk of renal calculi.", + "tags": [] + }, + { + "key": "Haematological", + "val": "CAUTION — Can precipitate hemolysis in patients with G6PD deficiency if given in massive IV doses.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Scurvy (Severe Deficiency)", + "val": "**PO** / **IV** 500-1000 mg/day in divided doses until symptoms resolve.", + "tags": [] + }, + { + "key": "Iron Absorption Enhancement", + "val": "**PO** 250-500 mg taken concurrently with oral iron supplements.", + "tags": [] + }, + { + "key": "Wound Healing (Burns/Ulcers)", + "val": "**PO** 500 mg **BD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Cecon, Redoxon", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (250, 500 mg). Chewable tablets. Effervescent tablets.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** / **IM** use (Hospital only).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention and treatment of scurvy, adjunctive wound healing, methemoglobinemia (if methylene blue unavailable).", + "tags": ["TGA"] + }, + { + "key": "Off-Label", + "val": "Used in toxicology to acidify the urine and flush out weak-base drugs (like Amphetamines).", + "tags": ["OFF"] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Hemochromatosis, Thalassemia (Vitamin C accelerates iron absorption and exacerbates iron overload toxicity).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A at nutritional/replacement doses.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Vitamin C replacement at nutritional doses is compatible with pregnancy." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "BENEFICIAL — Oral Iron (Ferrous sulfate). Vitamin C converts ferric iron (Fe3+) to ferrous iron (Fe2+), significantly boosting gut absorption.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Amphetamines (Dexamphetamine). Because high-dose Vitamin C intensely acidifies the urine, it traps amphetamines in the urine and forces their rapid excretion, ruining their clinical effect.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Vitamin C can cause false-negative results in stool occult blood tests. Cease 48h before testing.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "Scurvy is Real", + "val": "Scurvy is not just a pirate disease. Elderly patients living alone on a 'tea and toast' diet frequently present to the ward with spontaneous massive bruising, corkscrew body hairs, and bleeding gums. 500mg of Vitamin C cures it in days.", + "tags": [] + }, + { + "key": "The Sepsis Myth", + "val": "Despite popular 'alternative' protocols, massive IV Vitamin C infusions have completely failed in rigorous randomized controlled trials to improve survival or outcomes in severe ICU septic shock.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Electron donor (reducing agent). Essential co-factor for prolyl hydroxylase, which stabilizes the triple-helix structure of collagen. Without it, blood vessels and skin literally fall apart.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days for tissue repair.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Hours. The body has a strict saturation limit (~2000mg); anything beyond this is instantly dumped into the urine.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health vitamin C nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Water-Soluble — Vitamin C." + }, + { + "label": "Route / Formulation", + "value": "Tablets (250, 500 mg). Chewable tablets. Effervescent tablets. (Cecon, Redoxon)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** / **IV** 500-1000 mg/day in divided doses until symptoms resolve. Max **2000 mg/day** (Higher doses just cause severe osmotic diarrhea)." + }, + { + "label": "Key Indication Doses", + "value": "Scurvy (Severe Deficiency): **PO** / **IV** 500-1000 mg/day in divided doses until symptoms resolve. Iron Absorption Enhancement: **PO** 250-500 mg taken concurrently with oral iron supplements. Wound Healing (Burns/Ulcers): **PO** 500 mg **BD**." + }, + { + "label": "Best Uses", + "value": "Ascorbic Acid is used for scurvy treatment and prevention and as an adjunct in iron absorption, but mega-doses increase oxalate kidney stone risk and provide no proven benefit for cold prevention." + }, + { + "label": "Avoid / Cautions", + "value": "Hemochromatosis, Thalassemia (Vitamin C accelerates iron absorption and exacerbates iron overload toxicity). **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Osmotic diarrhea, severe abdominal cramping, nausea (virtually guaranteed at doses > 2g/day). Renal: Oxalate kidney stones. Vitamin C is metabolized to oxalate, and massive chronic doses increase the risk of renal calculi. Haematological: Can precipitate hemolysis in patients with G6PD deficiency if given in massive IV doses." + }, + { + "label": "Key Interactions", + "value": "BENEFICIAL — Oral Iron (Ferrous sulfate). Vitamin C converts ferric iron (Fe3+) to ferrous iron (Fe2+), significantly boosting gut absorption. Amphetamines (Dexamphetamine). Because high-dose Vitamin C intensely acidifies the urine, it traps amphetamines in the urine and forces their rapid excretion, ruining their clinical effect." + }, + { + "label": "Monitoring", + "value": "Vitamin C can cause false-negative results in stool occult blood tests. Cease 48h before testing." + }, + { + "label": "Clinical Pearl", + "value": "Scurvy is not just a pirate disease. Elderly patients living alone on a 'tea and toast' diet frequently present to the ward with spontaneous massive bruising, corkscrew body hairs, and bleeding gums. 500mg of Vitamin C cures it in days." + } + ] + }, + { + "slug": "calcium-carbonate", + "name": "Calcium carbonate", + "class": "Mineral", + "subclass": "Macromineral", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "MINERAL", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "2500 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Absorption", + "value": "ACID DEPENDENT", + "cls": "warn", + "flag": "" + }, + { + "label": "Binding Trap", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Constipation", + "value": "HIGH RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The most common and cheapest form of calcium supplementation. Highly dependent on stomach acid to dissolve. Acts as a potent binder of other drugs in the gut.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **2500 mg/day** (Total elemental calcium from diet + pills).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Cannot be taken simultaneously with Thyroxine, Iron, Doxycycline, or Ciprofloxacin. It will permanently bind them in the gut, causing clinical failure.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Calcium carbonate is a first-line calcium supplement for osteoporosis prevention and phosphate binding in CKD, but requires gastric acid for absorption (take with food) and can cause constipation and hypercalcaemia.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Severe constipation, bloating, flatulence.", + "tags": [] + }, + { + "key": "Metabolic", + "val": "HIGH — Hypercalcemia (especially if taking high-dose Vitamin D or thiazide diuretics), Milk-Alkali syndrome (metabolic alkalosis and renal failure).", + "tags": [] + }, + { + "key": "Renal", + "val": "HIGH — Nephrolithiasis (Calcium kidney stones).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Osteoporosis Adjunct / Supplement", + "val": "**PO** 600 mg (Elemental Calcium) **OD** or **BD**. Must be taken strictly WITH FOOD to stimulate stomach acid for absorption.", + "tags": [] + }, + { + "key": "Phosphate Binding (CKD)", + "val": "**PO** 1.25 - 2.5 g **TDS** (Taken strictly WITH MEALS to bind dietary phosphate before it absorbs).", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CAUTION — Can cause vascular calcification in severe CKD if overdosed.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Caltrate, Cal-Sup, Titralac", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (600 mg elemental calcium). Often combined with Vitamin D3.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Calcium supplementation in osteoporosis, hyperphosphatemia in end-stage renal failure, hypocalcemia.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Mandatory adjunct for patients on Denosumab or Bisphosphonates to provide the building blocks for bone remineralisation.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Pre-existing hypercalcemia, hypercalciuria, severe kidney stones.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A when used within recommended calcium intake.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Calcium replacement is compatible with pregnancy when kept within recommended intake." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Calcium chelates levothyroxine, iron, fluoroquinolones, tetracyclines, and bisphosphonates; separate doses by at least 2-4 hours, and keep bisphosphonates separate per their product directions.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Thiazide diuretics (HCTZ) reduce calcium excretion in the kidneys, massively increasing the risk of hypercalcemia.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Monitor **U&E** (Calcium, Phosphate, eGFR) regularly in CKD patients or those on concurrent high-dose Vitamin D.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Ensure prophylactic laxatives are considered in the frail elderly, as it acts like concrete in the bowel.", + "tags": [], + "patient": { + "factors": ["elderly"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "age": { + "gte": 65 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The PPI Trap", + "val": "Calcium Carbonate physically requires a highly acidic stomach (pH < 2) to dissolve into an absorbable form. If a patient is taking Pantoprazole or Esomeprazole (PPI), the stomach has no acid, and the Calcium Carbonate will pass straight through the bowel unabsorbed. For patients on PPIs, you MUST switch them to Calcium Citrate (Citracal), which dissolves independent of acid.", + "tags": [] + }, + { + "key": "The 500mg Limit", + "val": "The human gut can only absorb about 500-600mg of elemental calcium at one time through active transport. Taking two 600mg tablets at breakfast is useless; the second tablet will just cause constipation. Split them to morning and night.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Provides elemental calcium for bone matrix synthesis. In the gut, it acts as an alkaline buffer (antacid) and strongly chelates (binds) free phosphate and other multivalent drugs.", + "tags": [] + }, + { + "key": "Onset", + "val": "Hours (for antacid effect).", + "tags": [] + }, + { + "key": "Half-life", + "val": "Incorporated into bone or excreted in urine/feces.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health calcium nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Macromineral — The most common and cheapest form of calcium supplementation." + }, + { + "label": "Route / Formulation", + "value": "Tablets (600 mg elemental calcium). Often combined with Vitamin D3. (Caltrate, Cal-Sup, Titralac)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 600 mg (Elemental Calcium) **OD** or **BD**. Must be taken strictly WITH FOOD to stimulate stomach acid for absorption. Max **2500 mg/day** (Total elemental calcium from diet + pills)." + }, + { + "label": "Key Indication Doses", + "value": "Osteoporosis Adjunct / Supplement: **PO** 600 mg (Elemental Calcium) **OD** or **BD**. Must be taken strictly WITH FOOD to stimulate stomach acid for absorption. Phosphate Binding (CKD): **PO** 1.25 - 2.5 g **TDS** (Taken strictly WITH MEALS to bind dietary phosphate before it absorbs). Renal Impairment: Can cause vascular calcification in severe CKD if overdosed." + }, + { + "label": "Best Uses", + "value": "Calcium carbonate is a first-line calcium supplement for osteoporosis prevention and phosphate binding in CKD, but requires gastric acid for absorption (take with food) and can cause constipation and hypercalcaemia." + }, + { + "label": "Avoid / Cautions", + "value": "Pre-existing hypercalcemia, hypercalciuria, severe kidney stones. **Pregnancy** Category A. Demands increase in 3rd trimester." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe constipation, bloating, flatulence. Metabolic: Hypercalcemia (especially if taking high-dose Vitamin D or thiazide diuretics), Milk-Alkali syndrome (metabolic alkalosis and renal failure). Renal: Nephrolithiasis (Calcium kidney stones)." + }, + { + "label": "Key Interactions", + "value": "Levothyroxine (Oroxine), Iron, Fluoroquinolones (Ciprofloxacin), Tetracyclines (Doxycycline), Bisphosphonates. Calcium forms an indestructible physical 'brick' with these drugs in the stomach. You MUST separate doses by a minimum of 2 to 4 hours. Thiazide diuretics (HCTZ) reduce calcium excretion in the kidneys, massively increasing the risk of hypercalcemia." + }, + { + "label": "Monitoring", + "value": "Monitor **U&E** (Calcium, Phosphate, eGFR) regularly in CKD patients or those on concurrent high-dose Vitamin D. Ensure prophylactic laxatives are considered in the frail elderly, as it acts like concrete in the bowel." + }, + { + "label": "Clinical Pearl", + "value": "Calcium Carbonate physically requires a highly acidic stomach (pH < 2) to dissolve into an absorbable form. If a patient is taking Pantoprazole or Esomeprazole (PPI), the stomach has no acid, and the Calcium Carbonate will pass straight through the bowel unabsorbed. For patients on PPIs, you MUST switch them to Calcium Citrate (Citracal), which dissolves independent of acid." + } + ] + }, + { + "slug": "copper", + "name": "Copper", + "class": "Mineral", + "subclass": "Trace Element", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "MINERAL", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Wilson's Dis.", + "value": "FATAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Anemia", + "value": "COFACTOR", + "cls": "good", + "flag": "" + }, + { + "label": "Zinc Tox", + "value": "CAUSES DEFICIENCY", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Trace mineral required for iron absorption, nerve myelination, and collagen cross-linking. Highly toxic in excess.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg/day** (Tolerable Upper Limit).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Strictly contraindicated in Wilson's Disease. Deficiency perfectly mimics B12 deficiency (severe spinal cord degeneration).", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Copper is an essential trace element for haematopoiesis and connective tissue, but supplementation is rarely needed and excess causes hepatotoxicity (Wilson's disease phenocopy).", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Hepatic", + "val": "CRITICAL — Severe hepatotoxicity, cirrhosis, and massive hemolysis (seen in Wilson's disease where copper cannot be excreted).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Nausea, vomiting, blue-green vomit (in acute toxicity).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Copper Deficiency", + "val": "**PO** 2-4 mg **OD** until replenished.", + "tags": [] + }, + { + "key": "TPN Additive", + "val": "**IV** Included in standard trace element vials.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Various OTC", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention and treatment of copper deficiency (often secondary to massive zinc supplementation, bariatric surgery, or long-term TPN).", + "tags": ["TGA"] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Wilson disease or severe cholestatic/biliary liver disease where copper excretion is impaired.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Copper supplementation is unsafe when copper excretion is impaired by severe cholestatic/biliary liver disease." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Zinc. Massive doses of oral Zinc induce proteins in the gut that trap Copper and poop it out. The #1 cause of Copper deficiency on the ward is a doctor prescribing high-dose Zinc for a bed-sore for 6 months.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — If a patient has unexplained anemia and severe peripheral neuropathy, but their B12 is normal, check a Serum Copper level.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Iron Link", + "val": "You cannot fix iron deficiency if the patient is copper deficient. Copper (via ceruloplasmin) is the 'forklift' that loads iron into the blood. Without copper, the iron just sits uselessly in the liver.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Cofactor for ceruloplasmin (loads iron onto transferrin), cytochrome c oxidase (ATP production), and lysyl oxidase (collagen synthesis).", + "tags": [] + }, + { + "key": "Onset", + "val": "Weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Excreted purely in the bile/feces. (If bile ducts are blocked, copper accumulates fatally).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health copper nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Trace Element — Trace mineral required for iron absorption, nerve myelination, and collagen cross-linking." + }, + { + "label": "Route / Formulation", + "value": "Tablets. (Various OTC)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 2-4 mg **OD** until replenished. Max **10 mg/day** (Tolerable Upper Limit)." + }, + { + "label": "Key Indication Doses", + "value": "Copper Deficiency: **PO** 2-4 mg **OD** until replenished. TPN Additive: **IV** Included in standard trace element vials." + }, + { + "label": "Best Uses", + "value": "Copper is an essential trace element for haematopoiesis and connective tissue, but supplementation is rarely needed and excess causes hepatotoxicity (Wilson's disease phenocopy)." + }, + { + "label": "Avoid / Cautions", + "value": "Wilson's Disease, severe biliary cirrhosis/cholestasis (cannot excrete it)." + }, + { + "label": "Key Risks", + "value": "Hepatic: Severe hepatotoxicity, cirrhosis, and massive hemolysis (seen in Wilson's disease where copper cannot be excreted). Gastrointestinal: Nausea, vomiting, blue-green vomit (in acute toxicity)." + }, + { + "label": "Key Interactions", + "value": "Zinc. Massive doses of oral Zinc induce proteins in the gut that trap Copper and poop it out. The #1 cause of Copper deficiency on the ward is a doctor prescribing high-dose Zinc for a bed-sore for 6 months." + }, + { + "label": "Monitoring", + "value": "If a patient has unexplained anemia and severe peripheral neuropathy, but their B12 is normal, check a Serum Copper level." + }, + { + "label": "Clinical Pearl", + "value": "You cannot fix iron deficiency if the patient is copper deficient. Copper (via ceruloplasmin) is the 'forklift' that loads iron into the blood. Without copper, the iron just sits uselessly in the liver." + } + ] + }, + { + "slug": "folic-acid", + "name": "Folic acid", + "class": "Vitamin", + "subclass": "Water-Soluble (B9)", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "VITAMIN", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Dose", + "value": "5 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "Hours", + "cls": "", + "flag": "" + }, + { + "label": "MTX Rescue", + "value": "MANDATORY", + "cls": "good", + "flag": "warn" + }, + { + "label": "Pregnancy", + "value": "NEURAL TUBE", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Vitamin B9. Synthetic folate. Absolutely essential for DNA synthesis, red blood cell formation, and fetal neural tube development.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **5 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Essential before and during early pregnancy for neural tube defect prevention; exclude or treat vitamin B12 deficiency before high-dose folate for megaloblastic anaemia.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Folic acid is critical for neural tube defect prevention in pregnancy and managing folate deficiency, but must never be given alone if B12 deficiency is not excluded as it can mask and worsen neurological damage.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Can mask Vitamin B12 deficiency. If high-dose folate is given to a B12-deficient patient, the anemia improves, but the irreversible neurological damage (subacute combined degeneration of the cord) silently accelerates.", + "tags": [] + }, + { + "key": "Systemic", + "val": "SAFE — Extremely benign profile. Virtually zero toxicity as excess is peed out.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Megaloblastic Anemia", + "val": "**PO** 5 mg **OD** for 4 months.", + "tags": [] + }, + { + "key": "Pregnancy Prophylaxis", + "val": "**PO** 0.5 mg **OD** (Start 1 month before conception). Give 5 mg OD if high risk (e.g., on Valproate/Carbamazepine).", + "tags": [] + }, + { + "key": "Methotrexate Rescue", + "val": "MANDATORY — **PO** 5 mg ONCE WEEKLY. Must be taken 1 to 2 days *after* the Methotrexate dose.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Megafol", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (0.5 mg, 5 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** / **IM** (Rarely used, oral absorption is near 100%).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Folate deficiency megaloblastic anemia, prevention of neural tube defects, adjunct to Methotrexate therapy.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Foundational supplement in antenatal care and rheumatology.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Undiagnosed megaloblastic anemia (Must check B12 levels first to rule out pernicious anemia).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE / INDICATED — **Pregnancy** Category A; routine preconception/early-pregnancy supplementation, with high-dose folate for higher-risk patients.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Folic acid is pregnancy-indicated, not a contraindication alert." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Methotrexate. Folate replaces the exact compound Methotrexate is trying to starve the body of. If taken on the *same day*, the Folate will cancel out the Methotrexate, causing a severe arthritis flare. Must be staggered.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Phenytoin and Barbiturates lower folate levels, and paradoxically, giving folate can lower Phenytoin levels, risking seizures.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Always check both Serum Folate AND Vitamin B12 levels together before initiating treatment. Monitor **FBC**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Anticonvulsant Risk", + "val": "Women taking Valproate or Carbamazepine for epilepsy are at a massively increased risk of having a baby with spina bifida (due to folate depletion). They MUST be on the high-dose 5 mg folic acid tablet, not the standard 0.5 mg pregnancy multivitamin.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Converted in the body to tetrahydrofolate. Acts as a methyl donor for the synthesis of purines and pyrimidines (DNA/RNA). Essential for normal erythropoiesis.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days (Reticulocyte count peaks in 5-7 days).", + "tags": [] + }, + { + "key": "Half-life", + "val": "Hours (Water soluble, excess is rapidly excreted in urine).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health folate nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Water-Soluble (B9) — Vitamin B9." + }, + { + "label": "Route / Formulation", + "value": "Tablets (0.5 mg, 5 mg). (Megafol)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 5 mg **OD** for 4 months. Max **5 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Megaloblastic Anemia: **PO** 5 mg **OD** for 4 months. Pregnancy Prophylaxis: **PO** 0.5 mg **OD** (Start 1 month before conception). Give 5 mg OD if high risk (e.g., on Valproate/Carbamazepine). Methotrexate Rescue: **PO** 5 mg ONCE WEEKLY. Must be taken 1 to 2 days *after* the Methotrexate dose." + }, + { + "label": "Best Uses", + "value": "Folic acid is critical for neural tube defect prevention in pregnancy and managing folate deficiency, but must never be given alone if B12 deficiency is not excluded as it can mask and worsen neurological damage." + }, + { + "label": "Avoid / Cautions", + "value": "Undiagnosed megaloblastic anemia (Must check B12 levels first to rule out pernicious anemia). **Pregnancy** Category A. Mandatory requirement." + }, + { + "label": "Key Risks", + "value": "Neurological: Can mask Vitamin B12 deficiency. If high-dose folate is given to a B12-deficient patient, the anemia improves, but the irreversible neurological damage (subacute combined degeneration of the cord) silently accelerates. Systemic: Extremely benign profile. Virtually zero toxicity as excess is peed out." + }, + { + "label": "Key Interactions", + "value": "Methotrexate. Folate replaces the exact compound Methotrexate is trying to starve the body of. If taken on the *same day*, the Folate will cancel out the Methotrexate, causing a severe arthritis flare. Must be staggered. Phenytoin and Barbiturates lower folate levels, and paradoxically, giving folate can lower Phenytoin levels, risking seizures." + }, + { + "label": "Monitoring", + "value": "Always check both Serum Folate AND Vitamin B12 levels together before initiating treatment. Monitor **FBC**." + }, + { + "label": "Clinical Pearl", + "value": "Women taking Valproate or Carbamazepine for epilepsy are at a massively increased risk of having a baby with spina bifida (due to folate depletion). They MUST be on the high-dose 5 mg folic acid tablet, not the standard 0.5 mg pregnancy multivitamin." + } + ] + }, + { + "slug": "iodine", + "name": "Iodine", + "class": "Mineral", + "subclass": "Trace Element", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "MINERAL", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "Varies", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Thyroid Storm", + "value": "RESCUE DRUG", + "cls": "good", + "flag": "warn" + }, + { + "label": "Wolff-Chaikoff", + "value": "BLOCKS THYROID", + "cls": "good", + "flag": "" + }, + { + "label": "Timing", + "value": "AFTER PTU", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Essential trace element for making thyroid hormone. However, given in MASSIVE pharmacological doses, it paradoxically shuts the thyroid gland down completely (Wolff-Chaikoff effect).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Varies by indication (Drops of Lugol's solution).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Nutritional iodine is required in pregnancy, but pharmacological iodine for thyroid storm or radiation exposure is a separate high-dose treatment requiring specialist timing and fetal thyroid-risk review.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Iodine is essential for thyroid hormone synthesis and used in thyroid storm preparation, but excess can paradoxically cause both hypo- and hyperthyroidism (Wolff-Chaikoff/Jod-Basedow effects).", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Endocrine", + "val": "CRITICAL — Jod-Basedow phenomenon (Paradoxical induction of severe hyperthyroidism if given to a deficient patient).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "HIGH — Severe metallic taste, burning mouth/throat, GI bleeding (if undiluted).", + "tags": [] + }, + { + "key": "Immunological", + "val": "MODERATE — Iodism (chronic toxicity: brassy taste, severe acne-like rash, swollen salivary glands).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Thyrotoxic Crisis (Thyroid Storm)", + "val": "**PO** Lugol's Iodine: 3-5 drops **TDS** (Administer exactly 1 hour AFTER giving antithyroid drugs).", + "tags": [] + }, + { + "key": "Pre-operative Thyroidectomy", + "val": "**PO** Lugol's Iodine: 3-5 drops **TDS** for 10 days before surgery (Shrinks the gland and reduces blood flow, stopping the surgeon from causing massive bleeding).", + "tags": [] + }, + { + "key": "Radiation Emergency", + "val": "**PO** Potassium Iodide (KI) 130 mg STAT (Floods the thyroid with safe iodine, preventing it from absorbing radioactive iodine fallout).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Lugol's Solution (Aqueous iodine)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Liquid drops. MUST be diluted in water or juice (highly caustic to the throat).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital/Pharmacy supply.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Thyrotoxic crisis, preparation for thyroid surgery, nuclear radiation emergencies.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Emergency endocrine rescue drug.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Pre-existing iodine allergy, dermatitis herpetiformis.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CAUTION / SPECIALIST — Nutritional iodine is recommended in pregnancy, but high-dose pharmacological iodine can suppress fetal thyroid function and requires specialist benefit-risk review.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "caution", + "severity": "caution", + "note": "High-dose pharmacological iodine in pregnancy needs specialist fetal thyroid-risk review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Lithium (Additive hypothyroid effect).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the timing protocol (PTU first, Iodine second) is strictly adhered to in ICU.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Gland Shrinker", + "val": "Surgeons love Lugol's Iodine. A hyperactive thyroid gland is engorged with blood vessels and bleeds catastrophically when cut. 10 days of Lugol's drastically shrinks the vessels, turning it into a firm, safe gland to operate on.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Wolff-Chaikoff Effect: A sudden, massive influx of iodide acutely inhibits the organification of iodine and halts the release of pre-formed T3 and T4 from the thyroid gland.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 24 hours to drop hormone release.", + "tags": [] + }, + { + "key": "Duration", + "val": "The 'blockade' effect only lasts 1-2 weeks before the thyroid 'escapes' and resumes pumping out hormone.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health iodine nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Trace Element — Essential trace element for making thyroid hormone." + }, + { + "label": "Route / Formulation", + "value": "Liquid drops. MUST be diluted in water or juice (highly caustic to the throat). (Lugol's Solution (Aqueous iodine))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** Lugol's Iodine: 3-5 drops **TDS** (Administer exactly 1 hour AFTER giving antithyroid drugs). Varies by indication (Drops of Lugol's solution)." + }, + { + "label": "Key Indication Doses", + "value": "Thyrotoxic Crisis (Thyroid Storm): **PO** Lugol's Iodine: 3-5 drops **TDS** (Administer exactly 1 hour AFTER giving antithyroid drugs). Pre-operative Thyroidectomy: **PO** Lugol's Iodine: 3-5 drops **TDS** for 10 days before surgery (Shrinks the gland and reduces blood flow, stopping the surgeon from causing massive bleeding). Radiation Emergency: **PO** Potassium Iodide (KI) 130 mg STAT (Floods the thyroid with safe iodine, preventing it from absorbing radioactive iodine fallout)." + }, + { + "label": "Best Uses", + "value": "Iodine is essential for thyroid hormone synthesis and used in thyroid storm preparation, but excess can paradoxically cause both hypo- and hyperthyroidism (Wolff-Chaikoff/Jod-Basedow effects)." + }, + { + "label": "Avoid / Cautions", + "value": "Pre-existing iodine allergy, dermatitis herpetiformis. **Pregnancy** Category D (High doses cause massive fetal goitre, asphyxiating the baby)." + }, + { + "label": "Key Risks", + "value": "Endocrine: Jod-Basedow phenomenon (Paradoxical induction of severe hyperthyroidism if given to a deficient patient). Gastrointestinal: Severe metallic taste, burning mouth/throat, GI bleeding (if undiluted). Immunological: Iodism (chronic toxicity: brassy taste, severe acne-like rash, swollen salivary glands)." + }, + { + "label": "Key Interactions", + "value": "Lithium (Additive hypothyroid effect)." + }, + { + "label": "Monitoring", + "value": "Ensure the timing protocol (PTU first, Iodine second) is strictly adhered to in ICU." + }, + { + "label": "Clinical Pearl", + "value": "Surgeons love Lugol's Iodine. A hyperactive thyroid gland is engorged with blood vessels and bleeds catastrophically when cut. 10 days of Lugol's drastically shrinks the vessels, turning it into a firm, safe gland to operate on." + } + ] + }, + { + "slug": "iron", + "name": "Iron", + "class": "Mineral", + "subclass": "Trace Element", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "MINERAL", + "schedule": "S4", + "stats": [ + { + "label": "Dose", + "value": "100 mg Elemental", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Freq", + "value": "ALTERNATE DAYS", + "cls": "good", + "flag": "warn" + }, + { + "label": "Anaphylaxis", + "value": "IV RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Stool Color", + "value": "BLACK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Essential trace element required for haemoglobin synthesis. Oral forms are poorly tolerated and require specific acidic environments to absorb. IV forms bypass the gut but carry a risk of hypersensitivity.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **100-200 mg Elemental Iron** per day (PO). Note: 325 mg of Ferrous Sulfate contains only ~100 mg of actual elemental iron.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Confirm iron deficiency and likely cause, then choose oral alternate-day dosing or IV iron based on severity, tolerance, pregnancy trimester, and urgency.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Iron is first-line treatment for iron deficiency anaemia, but oral formulations cause significant GI intolerance (take on empty stomach with vitamin C) and IV iron carries anaphylaxis risk.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Severe constipation, nausea, dark black/tarry stools, abdominal cramping (PO iron is extremely harsh on the stomach).", + "tags": [] + }, + { + "key": "Immunological", + "val": "CRITICAL — IV formulations carry a rare but severe risk of hypersensitivity/anaphylactoid reactions and severe hypophosphatemia (Ferrinject specifically drops serum phosphate).", + "tags": [] + }, + { + "key": "Tissue", + "val": "HIGH — IV iron extravasation permanently 'tattoos' the patient's skin a dark rusty brown color. Irreversible. Must ensure IV line is pristine.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Iron Deficiency Anemia (Oral)", + "val": "**PO** 100 mg elemental iron (e.g., 1 tablet of Ferro-gradumet) EVERY SECOND DAY, taken on an empty stomach with a glass of orange juice (Vitamin C).", + "tags": [] + }, + { + "key": "Iron Infusion (IV)", + "val": "**IV** Ferric carboxymaltose (Ferrinject) 500 mg - 1000 mg infused strictly over 15 mins. Max 1000 mg/week.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Ferro-gradumet (Sulfate), FGF (with Folate), Maltofer (Polymaltose), Ferrinject (IV)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets, Oral Liquid (Stains teeth black, use a straw).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Vials for **IV** infusion.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (PO). PBS Restricted (IV).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Iron deficiency anemia (IDA).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line oral replenishment. IV is reserved for patients who fail PO, cannot tolerate the GI side effects, or require rapid Hb restoration pre-surgery/3rd trimester.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Hemochromatosis, hemosiderosis, anemia NOT caused by iron deficiency (e.g., Thalassemia, B12 deficiency).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE / INDICATED — Oral iron is compatible with pregnancy when deficiency is present; IV iron is usually specialist-guided and generally avoided in the first trimester unless benefits clearly outweigh risk.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Iron replacement is commonly indicated in pregnancy when deficiency is confirmed; IV use needs trimester and benefit-risk review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Calcium, Antacids, Milk, Tea, Coffee. These instantly bind iron in the gut, dropping absorption to near ZERO. Separate by 2-4 hours.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Doxycycline, Ciprofloxacin, Thyroxine, Levodopa. Iron binds to these drugs and destroys their absorption. Separate strictly by 2-4 hours.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "BENEFICIAL — Vitamin C (Ascorbic Acid) drastically acidifies the stomach and keeps iron in the absorbable Fe2+ state, boosting absorption by 30%.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Monitor **FBC**, Ferritin, and Iron Studies. Do NOT recheck iron studies within 4 weeks of an IV infusion (ferritin will be falsely elevated). Monitor Phosphate post-IV.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Warn patients about black stools so they don't panic thinking they have a GI bleed.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Alternate Day Rule", + "val": "When you take an iron pill, the liver releases Hepcidin, a hormone that slams the iron absorption doors in the gut shut for 24-48 hours. Taking iron twice a day is completely useless; it just builds up in the colon and causes agonizing constipation. Taking it Monday, Wednesday, Friday allows Hepcidin to reset, doubling absorption and halving side effects.", + "tags": [] + }, + { + "key": "The Stool Fake-Out", + "val": "Iron turns the stool black and tarry, which perfectly mimics melaena (a bleeding upper GI ulcer). If a patient on iron has a black stool but their Hb is rising and urea is normal, it's just the iron.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Absorbed in the duodenum in the ferrous (Fe2+) state. Binds to transferrin in the blood, delivered to the bone marrow, and incorporated into the porphyrin ring to form haemoglobin.", + "tags": [] + }, + { + "key": "Onset", + "val": "Reticulocyte count peaks in 7-10 days. Hb rises by ~10g/L every 2-3 weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "The body has no active physiological mechanism for excreting iron (only lost through bleeding or sloughed skin cells).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: Ferinject Australian CMI plus NHMRC/Eat For Health iron nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Trace Element — Essential trace element required for haemoglobin synthesis." + }, + { + "label": "Route / Formulation", + "value": "Tablets, Oral Liquid (Stains teeth black, use a straw). (Ferro-gradumet (Sulfate), FGF (with Folate), Maltofer (Polymaltose), Ferrinject (IV))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 100 mg elemental iron (e.g., 1 tablet of Ferro-gradumet) EVERY SECOND DAY, taken on an empty stomach with a glass of orange juice (Vitamin C). Max **100-200 mg Elemental Iron** per day (PO). Note: 325 mg of Ferrous Sulfate contains only ~100 mg of actual elemental iron." + }, + { + "label": "Key Indication Doses", + "value": "Iron Deficiency Anemia (Oral): **PO** 100 mg elemental iron (e.g., 1 tablet of Ferro-gradumet) EVERY SECOND DAY, taken on an empty stomach with a glass of orange juice (Vitamin C). Iron Infusion (IV): **IV** Ferric carboxymaltose (Ferrinject) 500 mg - 1000 mg infused strictly over 15 mins. Max 1000 mg/week." + }, + { + "label": "Best Uses", + "value": "Iron is first-line treatment for iron deficiency anaemia, but oral formulations cause significant GI intolerance (take on empty stomach with vitamin C) and IV iron carries anaphylaxis risk." + }, + { + "label": "Avoid / Cautions", + "value": "Hemochromatosis, hemosiderosis, anemia NOT caused by iron deficiency (e.g., Thalassemia, B12 deficiency). **Pregnancy** Category A (Oral). IV iron is widely used in the 2nd and 3rd trimesters but generally avoided in the 1st." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe constipation, nausea, dark black/tarry stools, abdominal cramping (PO iron is extremely harsh on the stomach). Immunological: IV formulations carry a rare but severe risk of hypersensitivity/anaphylactoid reactions and severe hypophosphatemia (Ferrinject specifically drops serum phosphate). Tissue: IV iron extravasation permanently 'tattoos' the patient's skin a dark rusty brown color. Irreversible. Must ensure IV line is pristine." + }, + { + "label": "Key Interactions", + "value": "Calcium, Antacids, Milk, Tea, Coffee. These instantly bind iron in the gut, dropping absorption to near ZERO. Separate by 2-4 hours. Doxycycline, Ciprofloxacin, Thyroxine, Levodopa. Iron binds to these drugs and destroys their absorption. Separate strictly by 2-4 hours. BENEFICIAL — Vitamin C (Ascorbic Acid) drastically acidifies the stomach and keeps iron in the absorbable Fe2+ state, boosting absorption by 30%." + }, + { + "label": "Monitoring", + "value": "Monitor **FBC**, Ferritin, and Iron Studies. Do NOT recheck iron studies within 4 weeks of an IV infusion (ferritin will be falsely elevated). Monitor Phosphate post-IV. Warn patients about black stools so they don't panic thinking they have a GI bleed." + }, + { + "label": "Clinical Pearl", + "value": "When you take an iron pill, the liver releases Hepcidin, a hormone that slams the iron absorption doors in the gut shut for 24-48 hours. Taking iron twice a day is completely useless; it just builds up in the colon and causes agonizing constipation. Taking it Monday, Wednesday, Friday allows Hepcidin to reset, doubling absorption and halving side effects." + } + ] + }, + { + "slug": "magnesium-oxide", + "name": "Magnesium oxide", + "class": "Mineral", + "subclass": "Macromineral", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "MINERAL PO", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "1000 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Bioavailability", + "value": "POOR (4%)", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Diarrhea", + "value": "SEVERE RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Replacement", + "value": "USELESS", + "cls": "hi", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Inorganic magnesium salt. Notoriously cheap, but has a miserable 4% oral bioavailability. Mostly stays in the gut where it acts as a potent osmotic laxative.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1000 mg/day**.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Do not use Magnesium Oxide to replenish low blood magnesium levels. It does not absorb. Use Magnesium Aspartate or Citrate instead.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Magnesium oxide is a common oral magnesium supplement and osmotic laxative, but has the poorest oral bioavailability of all magnesium salts and frequently causes diarrhoea.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Severe, watery diarrhea, cramping.", + "tags": [] + }, + { + "key": "Renal", + "val": "HIGH — Hypermagnesemia (only if the patient has severe renal failure where the tiny 4% absorbed cannot be excreted).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "dose-adjust", + "severity": "caution", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Constipation (Off-label)", + "val": "**PO** 500-1000 mg **OD** (Used as an osmotic laxative).", + "tags": [] + }, + { + "key": "Magnesium Supplementation", + "val": "Avoid. Switch to Mg Aspartate (Magmin) or Mg Citrate.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Various OTC", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Historically used for magnesium deficiency.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Largely obsolete for electrolyte replacement. Only useful if you want to cause diarrhea.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Avoid unsupervised magnesium supplementation in severe renal impairment because accumulation can cause hypermagnesaemia and neuromuscular/cardiac toxicity.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Magnesium supplementation can accumulate in severe renal impairment." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Binds to Tetracyclines (Doxycycline) and Fluoroquinolones (Ciprofloxacin) in the gut, completely destroying their antibiotic absorption. Separate by 4 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "Warn the patient about diarrhea.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Pharmacy Trap", + "val": "Patients go to the pharmacy to buy 'Magnesium' for leg cramps and buy the cheapest bottle. It is always Magnesium Oxide. They come back complaining of explosive diarrhea and still having leg cramps. Tell them to specifically look at the label and buy Magnesium Citrate, Aspartate, or Glycinate (which have 40-50% absorption).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Inorganic salt. Fails to dissolve well in stomach acid. Pulls water into the intestines osmotically.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 6-12 hours (for laxative effect).", + "tags": [] + }, + { + "key": "Half-life", + "val": "N/A. 96% is excreted in feces unabsorbed.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health magnesium nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Macromineral — Inorganic magnesium salt." + }, + { + "label": "Route / Formulation", + "value": "Tablets. (Various OTC)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 500-1000 mg **OD** (Used as an osmotic laxative). Max **1000 mg/day**." + }, + { + "label": "Key Indication Doses", + "value": "Constipation (Off-label): **PO** 500-1000 mg **OD** (Used as an osmotic laxative). Magnesium Supplementation: Avoid. Switch to Mg Aspartate (Magmin) or Mg Citrate." + }, + { + "label": "Best Uses", + "value": "Magnesium oxide is a common oral magnesium supplement and osmotic laxative, but has the poorest oral bioavailability of all magnesium salts and frequently causes diarrhoea." + }, + { + "label": "Avoid / Cautions", + "value": "Severe renal impairment (**eGFR** < 30)." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe, watery diarrhea, cramping. Renal: Hypermagnesemia (only if the patient has severe renal failure where the tiny 4% absorbed cannot be excreted)." + }, + { + "label": "Key Interactions", + "value": "Binds to Tetracyclines (Doxycycline) and Fluoroquinolones (Ciprofloxacin) in the gut, completely destroying their antibiotic absorption. Separate by 4 hours." + }, + { + "label": "Monitoring", + "value": "Warn the patient about diarrhea." + }, + { + "label": "Clinical Pearl", + "value": "Patients go to the pharmacy to buy 'Magnesium' for leg cramps and buy the cheapest bottle. It is always Magnesium Oxide. They come back complaining of explosive diarrhea and still having leg cramps. Tell them to specifically look at the label and buy Magnesium Citrate, Aspartate, or Glycinate (which have 40-50% absorption)." + } + ] + }, + { + "slug": "magnesium-sulfate", + "name": "Magnesium sulfate", + "class": "Mineral", + "subclass": "Macromineral", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "MINERAL IV", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "20 mmol/hr (IV)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "Minutes (Distribution)", + "cls": "", + "flag": "" + }, + { + "label": "Reflexes", + "value": "LOSS = TOXICITY", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Asthma/Eclampsia", + "value": "RESCUE DRUG", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The ultimate intravenous smooth-muscle relaxant and membrane stabilizer. Used in critical emergencies for severe asthma, Eclampsia (seizures in pregnancy), and Torsades de Pointes.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated closely. Standard emergency IV bolus is 10-20 mmol (2.5-5 g) over 20 mins.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Magnesium toxicity paralyzes the diaphragm. The first sign of impending respiratory arrest is the loss of deep tendon (patellar) reflexes.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Magnesium sulfate is essential for eclampsia prophylaxis/treatment and severe hypomagnesaemia, but IV infusion requires reflexes and respiratory monitoring to prevent fatal overdose.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Hypermagnesemia causes sequential paralysis: Loss of deep tendon reflexes -> Somnolence -> Flaccid paralysis -> Apnoea -> Asystole/Cardiac Arrest.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Severe hypotension, vasodilation, flushing (if pushed too fast IV).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "MODERATE — Nausea.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Torsades de Pointes (VT)", + "val": "**IV** 10 mmol (2.5 g) STAT push over 1-2 mins.", + "tags": [] + }, + { + "key": "Severe Asthma Exacerbation", + "val": "**IV** 10 mmol (2.5 g) infused over 20 minutes (Relaxes bronchial smooth muscle).", + "tags": [] + }, + { + "key": "Eclampsia / Pre-eclampsia", + "val": "**IV** 16 mmol (4 g) loading dose over 20 mins, followed by continuous infusion of 4 mmol/hour (1 g/hr).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Magnesium Sulfate 50%", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (usually 10 mmol or 2.5 g per 5 mL). Concentrated solution, MUST be diluted for infusions.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital OT/ICU/ED/Delivery Suite supply. S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Hypomagnesemia, Eclampsia (seizure prevention), Torsades de Pointes, severe acute asthma.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "A 'magic bullet' in ED/ICU that instantly stabilises cardiac membranes and relaxes spasmodic muscle.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Myasthenia Gravis (will instantly paralyze them), heart block, severe renal failure (eGFR < 15, will accumulate and cause coma).", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A; magnesium sulfate is standard therapy for eclampsia/pre-eclampsia seizure prevention and treatment with close reflex, respiratory, BP, and renal monitoring.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Magnesium sulfate is pregnancy-indicated for eclampsia/pre-eclampsia when monitored appropriately." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Calcium Channel Blockers (Nifedipine, Amlodipine). Combining IV Magnesium with high-dose CCBs causes profound, refractory hypotension and neuromuscular blockade.", + "tags": [] + }, + { + "key": "Pharmacodynamic", + "val": "HIGH — Non-depolarizing muscle relaxants (Rocuronium). Mag sulfate massively prolongs surgical paralysis.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Every 1-2 hours on infusion, you MUST test the patient's patellar (knee-jerk) reflex. If the reflex is absent, STOP the infusion immediately. Monitor **SpO2**, **RR**, and **BP**.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — Check **U&E** (Magnesium and Calcium levels) every 4-6 hours during prolonged infusions.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Antidote", + "val": "If you overdose IV Magnesium and the patient stops breathing, the direct physiological antidote is IV Calcium Gluconate (10 mL of 10% solution). It instantly kicks the magnesium off the receptors and restores muscle function.", + "tags": [] + }, + { + "key": "The Potassium Fix", + "val": "If a patient has severe hypokalemia (Low K+) and you keep giving them IV Potassium but their levels won't rise, check their Magnesium. Magnesium is required to keep the potassium channels in the kidney closed. Without it, the kidney dumps all the potassium you are giving. Fix the Mag to fix the Potassium.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Acts as a physiological calcium channel blocker. Blocks NMDA receptors (stopping seizures in eclampsia) and blocks calcium influx into smooth muscle (relaxing bronchioles and blood vessels).", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Duration", + "val": "30 mins post bolus.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Cleared entirely by the kidneys. Levels drop rapidly as it distributes into bone/intracellular space.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: Magnesium sulfate Australian CMI plus NHMRC/Eat For Health magnesium source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Macromineral — The ultimate intravenous smooth-muscle relaxant and membrane stabilizer." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (usually 10 mmol or 2.5 g per 5 mL). Concentrated solution, MUST be diluted for infusions. (Magnesium Sulfate 50%)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 10 mmol (2.5 g) STAT push over 1-2 mins. Titrated closely. Standard emergency IV bolus is 10-20 mmol (2.5-5 g) over 20 mins." + }, + { + "label": "Key Indication Doses", + "value": "Torsades de Pointes (VT): **IV** 10 mmol (2.5 g) STAT push over 1-2 mins. Severe Asthma Exacerbation: **IV** 10 mmol (2.5 g) infused over 20 minutes (Relaxes bronchial smooth muscle). Eclampsia / Pre-eclampsia: **IV** 16 mmol (4 g) loading dose over 20 mins, followed by continuous infusion of 4 mmol/hour (1 g/hr)." + }, + { + "label": "Best Uses", + "value": "Magnesium sulfate is essential for eclampsia prophylaxis/treatment and severe hypomagnesaemia, but IV infusion requires reflexes and respiratory monitoring to prevent fatal overdose." + }, + { + "label": "Avoid / Cautions", + "value": "Myasthenia Gravis (will instantly paralyze them), heart block, severe renal failure (eGFR < 15, will accumulate and cause coma). **Pregnancy** Category A. The absolute gold-standard therapy to prevent maternal death from eclamptic seizures." + }, + { + "label": "Key Risks", + "value": "Neurological: Hypermagnesemia causes sequential paralysis: Loss of deep tendon reflexes -> Somnolence -> Flaccid paralysis -> Apnoea -> Asystole/Cardiac Arrest. Cardiovascular: Severe hypotension, vasodilation, flushing (if pushed too fast IV). Gastrointestinal: Nausea." + }, + { + "label": "Key Interactions", + "value": "Calcium Channel Blockers (Nifedipine, Amlodipine). Combining IV Magnesium with high-dose CCBs causes profound, refractory hypotension and neuromuscular blockade. Non-depolarizing muscle relaxants (Rocuronium). Mag sulfate massively prolongs surgical paralysis." + }, + { + "label": "Monitoring", + "value": "Every 1-2 hours on infusion, you MUST test the patient's patellar (knee-jerk) reflex. If the reflex is absent, STOP the infusion immediately. Monitor **SpO2**, **RR**, and **BP**. Check **U&E** (Magnesium and Calcium levels) every 4-6 hours during prolonged infusions." + }, + { + "label": "Clinical Pearl", + "value": "If you overdose IV Magnesium and the patient stops breathing, the direct physiological antidote is IV Calcium Gluconate (10 mL of 10% solution). It instantly kicks the magnesium off the receptors and restores muscle function." + } + ] + }, + { + "slug": "niacin-nicotinamide", + "name": "Niacin / Nicotinamide", + "class": "Vitamin", + "subclass": "Water-Soluble (B3)", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "VITAMIN", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "1000 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "Hours", + "cls": "", + "flag": "" + }, + { + "label": "Skin Cancer", + "value": "PROPHYLAXIS", + "cls": "good", + "flag": "" + }, + { + "label": "Flushing", + "value": "NIACIN ONLY", + "cls": "warn", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Vitamin B3. Exists in two distinct forms: Niacin (Nicotinic Acid) which lowers lipids but causes horrific flushing, and Nicotinamide which does not flush and is used to prevent skin cancer.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1000 mg/day** (Nicotinamide for skin cancer).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never confuse the two forms. Niacin causes a massive, burning, full-body flush mediated by prostaglandins.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Niacin / Nicotinamide is used for pellagra treatment and as adjunctive lipid-lowering therapy, but causes intense flushing at therapeutic doses and hepatotoxicity with sustained-release forms.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Dermatological", + "val": "CRITICAL — The 'Niacin Flush' (intense redness, burning, itching of the face and torso). Only occurs with Nicotinic Acid, NOT Nicotinamide.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "HIGH — Severe hepatotoxicity with high-dose sustained-release Niacin.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Metabolic", + "val": "MODERATE — Niacin can worsen gout (hyperuricemia) and worsen blood sugars in diabetics.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Non-Melanoma Skin Cancer Prophylaxis", + "val": "**PO** Nicotinamide 500 mg **BD** (Proven in the ONTRAC trial to reduce new BCCs and SCCs by 23%).", + "tags": [] + }, + { + "key": "Pellagra (Severe Deficiency)", + "val": "**PO** Nicotinamide 100-300 mg/day.", + "tags": [] + }, + { + "key": "Dyslipidemia (Obsolete)", + "val": "**PO** Niacin (Nicotinic acid) up to 2000 mg/day.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Various OTC", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (500 mg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention of recurrent basal cell and squamous cell carcinomas (Nicotinamide). Treatment of Pellagra.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Nicotinamide 500mg BD is standard-of-care across Australia for elderly patients with heavily sun-damaged skin to stop continuous skin cancers.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Active liver disease, active peptic ulcer (for Niacin).", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "contraindication", + "severity": "danger", + "note": "Existing absolute row names active or severe hepatic disease/failure; highlight when hepatic context is entered." + } + }, + { + "key": "Pregnancy", + "val": "SAFE — Nutritional niacin/nicotinamide intake is compatible with pregnancy; high-dose pharmacological niacin should only be used after benefit-risk review.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Nutritional niacin/nicotinamide is compatible with pregnancy; high-dose pharmacological use needs review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Niacin combined with Statins exponentially increases the risk of rhabdomyolysis.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the patient buys 'Nicotinamide' (or Niacinamide), NOT 'Niacin' or 'Nicotinic Acid', to prevent the flushing reaction.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Aspirin Hack", + "val": "If a patient MUST take Niacin and suffers the horrific flush, it can be entirely blocked by taking 300mg of Aspirin 30 minutes before the Niacin. The flush is driven by prostaglandins, which aspirin blocks.", + "tags": [] + }, + { + "key": "The 4 D's of Pellagra", + "val": "Severe B3 deficiency causes Pellagra, characterized by Diarrhea, Dermatitis, Dementia, and ultimately, Death.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Precursor to NAD/NADP. Nicotinamide prevents ATP depletion and boosts DNA repair in skin cells after UV radiation damage, preventing the cells from mutating into cancers.", + "tags": [] + }, + { + "key": "Onset", + "val": "Months for skin protection.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Hours.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health niacin nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Water-Soluble (B3) — Vitamin B3." + }, + { + "label": "Route / Formulation", + "value": "Tablets (500 mg). (Various OTC)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** Nicotinamide 500 mg **BD** (Proven in the ONTRAC trial to reduce new BCCs and SCCs by 23%). Max **1000 mg/day** (Nicotinamide for skin cancer)." + }, + { + "label": "Key Indication Doses", + "value": "Non-Melanoma Skin Cancer Prophylaxis: **PO** Nicotinamide 500 mg **BD** (Proven in the ONTRAC trial to reduce new BCCs and SCCs by 23%). Pellagra (Severe Deficiency): **PO** Nicotinamide 100-300 mg/day. Dyslipidemia (Obsolete): **PO** Niacin (Nicotinic acid) up to 2000 mg/day." + }, + { + "label": "Best Uses", + "value": "Niacin / Nicotinamide is used for pellagra treatment and as adjunctive lipid-lowering therapy, but causes intense flushing at therapeutic doses and hepatotoxicity with sustained-release forms." + }, + { + "label": "Avoid / Cautions", + "value": "Active liver disease, active peptic ulcer (for Niacin). At standard dietary doses." + }, + { + "label": "Key Risks", + "value": "Dermatological: The 'Niacin Flush' (intense redness, burning, itching of the face and torso). Only occurs with Nicotinic Acid, NOT Nicotinamide. Hepatic: Severe hepatotoxicity with high-dose sustained-release Niacin. Metabolic: Niacin can worsen gout (hyperuricemia) and worsen blood sugars in diabetics." + }, + { + "label": "Key Interactions", + "value": "Niacin combined with Statins exponentially increases the risk of rhabdomyolysis." + }, + { + "label": "Monitoring", + "value": "Ensure the patient buys 'Nicotinamide' (or Niacinamide), NOT 'Niacin' or 'Nicotinic Acid', to prevent the flushing reaction." + }, + { + "label": "Clinical Pearl", + "value": "If a patient MUST take Niacin and suffers the horrific flush, it can be entirely blocked by taking 300mg of Aspirin 30 minutes before the Niacin. The flush is driven by prostaglandins, which aspirin blocks." + } + ] + }, + { + "slug": "potassium-chloride", + "name": "Potassium chloride", + "class": "Mineral", + "subclass": "Macromineral", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "MINERAL", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mmol/hr (IV)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "GI Ulceration", + "value": "HIGH RISK (PO)", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Rapid IV", + "value": "FATAL ARREST", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Renal Adj.", + "value": "MANDATORY", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "The primary intracellular cation. Essential for cardiac electrical stability. High-risk medication when given IV due to the potential for instant, fatal cardiac arrest.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mmol/hour** via peripheral IV line. Max **20 mmol/hour** via Central Line with continuous ECG.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "NEVER give IV Potassium as a rapid bolus. It is the lethal injection sequence. Must be heavily diluted and infused slowly via an infusion pump.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Potassium chloride is the standard replacement for hypokalaemia, but IV infusion must never exceed 10 mmol/hr peripherally due to risk of fatal cardiac arrhythmia and requires cardiac monitoring.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Cardiovascular", + "val": "CRITICAL — Hyperkalemia (K+ > 6.0) causing peaked T waves, widened QRS, sine-wave ECG, and fatal ventricular fibrillation/asystole. HIGH — Severe chemical phlebitis/vein burning via peripheral IV.", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "CRITICAL — Oral Span-K tablets can cause severe esophageal or gastric ulceration, perforation, and bleeding if they get stuck or sit on the mucosa without enough water.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Hypokalemia (Oral)", + "val": "**PO** 1-2 tablets (8-16 mmol) **BD** or **TDS**. Must be taken upright with a full glass of water with meals.", + "tags": [] + }, + { + "key": "Hypokalemia (IV Peripheral)", + "val": "**IV Infusion** 10 mmol in 100 mL Normal Saline over 1 hour. Maximum rate is 10 mmol/hr.", + "tags": [] + }, + { + "key": "Hypokalemia (IV Central)", + "val": "**IV Infusion** 10-20 mmol/hr via CVC strictly in ICU with ECG monitoring.", + "tags": [] + }, + { + "key": "Renal Impairment", + "val": "CRITICAL — Avoid routine potassium replacement in significant renal impairment unless clearly indicated and closely monitored; the risk is hyperkalaemia, arrhythmia, and death.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 30 + } + }, + "note": "Potassium replacement in significant renal impairment requires clear indication and close potassium/renal monitoring." + } + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Span-K, Chlorvescent (effervescent)", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Sustained-release wax-matrix tablets (600 mg = 8 mmol). Effervescent tablets (14 mmol).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Premixed IV bags (10 mmol/100 mL). Ampoules (10 mmol/10 mL) MUST BE DILUTED.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Unrestricted General Benefit (S4). Highly restricted ward protocols for IV.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention and treatment of hypokalemia (e.g., from Frusemide, severe vomiting/diarrhea, DKA insulin protocols).", + "tags": ["PBS", "TGA"] + }, + { + "key": "Clinical Place", + "val": "Crucial electrolyte replacement to prevent malignant ventricular arrhythmias.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Pre-existing hyperkalemia, severe renal failure, Addison's disease, concurrent use of potassium-sparing diuretics.", + "tags": [], + "patient": { + "factors": ["renal"], + "action": "contraindication", + "severity": "danger", + "match": { + "egfr": { + "lt": 15 + } + }, + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Gastrointestinal", + "val": "CRITICAL — Esophageal strictures, delayed gastric emptying (for solid tablets).", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — ACEi, ARBs, Spironolactone, Amiloride, NSAIDs, Tacrolimus. Co-administration drastically reduces renal K+ excretion, leading to massive hyperkalemia.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Ensure the peripheral IV line is flushing perfectly. Extravasation of potassium causes agonizing tissue necrosis. If the patient complains of burning, slow the rate or dilute further.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "MANDATORY — Strict **U&E** monitoring. Always check Magnesium levels (must be normal for K+ to stay in the cells).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Dextrose Trap", + "val": "Never mix IV Potassium in a bag of 5% Dextrose. The glucose in the bag will trigger the patient's pancreas to release insulin. The insulin will drive all the potassium directly into the cells, dropping the blood level and making the hypokalemia *worse*. Always run it in Normal Saline.", + "tags": [] + }, + { + "key": "The Ghost Pill", + "val": "Span-K uses a hard wax matrix that does not dissolve. The potassium leaches out, and the completely intact wax ghost-pill is pooped out. Warn the patient so they don't think the medication failed.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Replenishes intracellular potassium. Essential for maintaining the resting membrane potential of cardiac and skeletal muscle cells.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** Hours. **IV** Immediate.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Cleared by the kidneys (regulated by Aldosterone).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: SLOW-K potassium chloride Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Macromineral — The primary intracellular cation." + }, + { + "label": "Route / Formulation", + "value": "Sustained-release wax-matrix tablets (600 mg = 8 mmol). Effervescent tablets (14 mmol). (Span-K, Chlorvescent (effervescent))" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1-2 tablets (8-16 mmol) **BD** or **TDS**. Must be taken upright with a full glass of water with meals. Max **10 mmol/hour** via peripheral IV line." + }, + { + "label": "Key Indication Doses", + "value": "Hypokalemia (Oral): **PO** 1-2 tablets (8-16 mmol) **BD** or **TDS**. Must be taken upright with a full glass of water with meals. Hypokalemia (IV Peripheral): **IV Infusion** 10 mmol in 100 mL Normal Saline over 1 hour. Maximum rate is 10 mmol/hr. Hypokalemia (IV Central): **IV Infusion** 10-20 mmol/hr via CVC strictly in ICU with ECG monitoring. Renal Impairment: Do not give routinely if **eGFR** < 30. The kidneys cannot excrete excess, leading to hyperkalemia and death." + }, + { + "label": "Best Uses", + "value": "Potassium chloride is the standard replacement for hypokalaemia, but IV infusion must never exceed 10 mmol/hr peripherally due to risk of fatal cardiac arrhythmia and requires cardiac monitoring." + }, + { + "label": "Avoid / Cautions", + "value": "Pre-existing hyperkalemia, severe renal failure, Addison's disease, concurrent use of potassium-sparing diuretics." + }, + { + "label": "Key Risks", + "value": "Cardiovascular: Hyperkalemia (K+ > 6.0) causing peaked T waves, widened QRS, sine-wave ECG, and fatal ventricular fibrillation/asystole. HIGH — Severe chemical phlebitis/vein burning via peripheral IV. Gastrointestinal: Oral Span-K tablets can cause severe esophageal or gastric ulceration, perforation, and bleeding if they get stuck or sit on the mucosa without enough water." + }, + { + "label": "Key Interactions", + "value": "ACEi, ARBs, Spironolactone, Amiloride, NSAIDs, Tacrolimus. Co-administration drastically reduces renal K+ excretion, leading to massive hyperkalemia." + }, + { + "label": "Monitoring", + "value": "Ensure the peripheral IV line is flushing perfectly. Extravasation of potassium causes agonizing tissue necrosis. If the patient complains of burning, slow the rate or dilute further. Strict **U&E** monitoring. Always check Magnesium levels (must be normal for K+ to stay in the cells)." + }, + { + "label": "Clinical Pearl", + "value": "Never mix IV Potassium in a bag of 5% Dextrose. The glucose in the bag will trigger the patient's pancreas to release insulin. The insulin will drive all the potassium directly into the cells, dropping the blood level and making the hypokalemia *worse*. Always run it in Normal Saline." + } + ] + }, + { + "slug": "pyridoxine", + "name": "Pyridoxine", + "class": "Vitamin", + "subclass": "Water-Soluble (B6)", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "VITAMIN", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "200 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "15-20 Days", + "cls": "", + "flag": "" + }, + { + "label": "Neuropathy", + "value": "PREVENTION", + "cls": "good", + "flag": "" + }, + { + "label": "INH Rescue", + "value": "MANDATORY", + "cls": "good", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Vitamin B6. Critical coenzyme for amino acid metabolism and neurotransmitter synthesis (GABA). Mandatory co-prescription for patients on specific tuberculosis drugs.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **200 mg/day** (Chronic doses > 200mg cause paradoxical, severe nerve damage).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Must be co-prescribed with Isoniazid (INH) to prevent irreversible peripheral neuropathy.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Pyridoxine is used for isoniazid-induced neuropathy prevention and treatment of pyridoxine deficiency, but chronic high doses (>200 mg/day) paradoxically cause sensory neuropathy.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Paradoxical sensory neuropathy. If a patient takes massive 'mega-vitamin' doses (>200 mg/day) for months, B6 paradoxically destroys the peripheral sensory nerves, leaving the patient unable to walk or feel their feet. Highly dangerous.", + "tags": [] + }, + { + "key": "Dermatological", + "val": "LOW — Photosensitivity.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Isoniazid (TB) Neuropathy Prophylaxis", + "val": "**PO** 25-50 mg **OD** (Taken concurrently with INH).", + "tags": [] + }, + { + "key": "Morning Sickness (Pregnancy)", + "val": "**PO** 10-25 mg **TDS** to **QID**.", + "tags": [] + }, + { + "key": "Isoniazid Overdose / Seizures", + "val": "**IV** 5 grams STAT (Matches the mg-for-mg amount of Isoniazid ingested, specialist tox only).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Pyroxin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (25 mg, 100 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules for **IV** injection (Hospital only, stored in ED for toxicology).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention of drug-induced peripheral neuropathy, hyperemesis gravidarum, sideroblastic anemia.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "First-line therapy in pregnancy for morning sickness (often combined with Doxylamine).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "NONE — Essential vitamin.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A at recommended doses; used for nausea/vomiting of pregnancy within recommended dose limits.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Pyridoxine is compatible with pregnancy at recommended doses." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Isoniazid (INH) and Penicillamine actively deplete the body of B6, directly causing seizures and nerve death. You must replace it.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Levodopa. Pyridoxine accelerates the peripheral breakdown of Levodopa, stopping it from reaching the brain and ruining Parkinson's control (This interaction is largely bypassed by modern combo pills like Madopar, which contain Benserazide).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn patients taking B6 supplements for 'energy' or 'PMS' to never exceed the 200mg daily limit to protect their nervous system.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The INH Seizure", + "val": "If a patient deliberately overdoses on their Tuberculosis medication (Isoniazid), it wipes out all the B6 in their brain. Without B6, the brain cannot make GABA. The patient goes into untreatable, lethal status epilepticus. Diazepam will not work. The ONLY cure is a massive IV push of Pyridoxine.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Converted to pyridoxal phosphate (PLP). PLP is the mandatory cofactor for the enzyme glutamate decarboxylase, which synthesizes GABA (the brain's main calming neurotransmitter).", + "tags": [] + }, + { + "key": "Onset", + "val": "Days.", + "tags": [] + }, + { + "key": "Half-life", + "val": "15-20 Days (Stored in the liver and muscle).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health vitamin B6 nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Water-Soluble (B6) — Vitamin B6." + }, + { + "label": "Route / Formulation", + "value": "Tablets (25 mg, 100 mg). (Pyroxin)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 25-50 mg **OD** (Taken concurrently with INH). Max **200 mg/day** (Chronic doses > 200mg cause paradoxical, severe nerve damage)." + }, + { + "label": "Key Indication Doses", + "value": "Isoniazid (TB) Neuropathy Prophylaxis: **PO** 25-50 mg **OD** (Taken concurrently with INH). Morning Sickness (Pregnancy): **PO** 10-25 mg **TDS** to **QID**. Isoniazid Overdose / Seizures: **IV** 5 grams STAT (Matches the mg-for-mg amount of Isoniazid ingested, specialist tox only)." + }, + { + "label": "Best Uses", + "value": "Pyridoxine is used for isoniazid-induced neuropathy prevention and treatment of pyridoxine deficiency, but chronic high doses (>200 mg/day) paradoxically cause sensory neuropathy." + }, + { + "label": "Avoid / Cautions", + "value": "NONE — Essential vitamin. **Pregnancy** Category A. Widely utilized in 1st trimester." + }, + { + "label": "Key Risks", + "value": "Neurological: Paradoxical sensory neuropathy. If a patient takes massive 'mega-vitamin' doses (>200 mg/day) for months, B6 paradoxically destroys the peripheral sensory nerves, leaving the patient unable to walk or feel their feet. Highly dangerous. Dermatological: Photosensitivity." + }, + { + "label": "Key Interactions", + "value": "Isoniazid (INH) and Penicillamine actively deplete the body of B6, directly causing seizures and nerve death. You must replace it. Levodopa. Pyridoxine accelerates the peripheral breakdown of Levodopa, stopping it from reaching the brain and ruining Parkinson's control (This interaction is largely bypassed by modern combo pills like Madopar, which contain Benserazide)." + }, + { + "label": "Monitoring", + "value": "Warn patients taking B6 supplements for 'energy' or 'PMS' to never exceed the 200mg daily limit to protect their nervous system." + }, + { + "label": "Clinical Pearl", + "value": "If a patient deliberately overdoses on their Tuberculosis medication (Isoniazid), it wipes out all the B6 in their brain. Without B6, the brain cannot make GABA. The patient goes into untreatable, lethal status epilepticus. Diazepam will not work. The ONLY cure is a massive IV push of Pyridoxine." + } + ] + }, + { + "slug": "riboflavin", + "name": "Riboflavin", + "class": "Vitamin", + "subclass": "Water-Soluble (B2)", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "VITAMIN", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "400 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "Hours", + "cls": "", + "flag": "" + }, + { + "label": "Migraine", + "value": "PROPHYLAXIS", + "cls": "good", + "flag": "" + }, + { + "label": "Urine Color", + "value": "NEON YELLOW", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Vitamin B2. Essential water-soluble vitamin involved in cellular energy production (FAD/FMN). Extremely safe. Extensively used in neurology for migraine prevention.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mg/day** (For migraines).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Will turn the patient's urine a glowing, fluorescent neon yellow. Must warn them to prevent panic.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Riboflavin is used for migraine prophylaxis and riboflavin deficiency, but causes harmless bright yellow urine and has limited evidence for most supplementation claims.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Genitourinary", + "val": "MODERATE — Intense neon-yellow discoloration of urine (Flavinuria). Harmless.", + "tags": [] + }, + { + "key": "Systemic", + "val": "SAFE — Virtually zero toxicity. Cannot overdose due to water solubility and limited gut absorption.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Migraine Prophylaxis", + "val": "**PO** 400 mg **OD** (Requires 3 months of use to see efficacy).", + "tags": [] + }, + { + "key": "Ariboflavinosis (Deficiency)", + "val": "**PO** 5-30 mg/day.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Various OTC", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets, Capsules.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Migraine prophylaxis, Vitamin B2 deficiency (stomatitis, glossitis, cheilosis).", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "A superb, completely non-toxic, highly effective preventative treatment for chronic migraines. Often used as first-line before starting toxic drugs like Topiramate or Amitriptyline.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "NONE.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — Riboflavin is compatible with pregnancy at nutritional doses; migraine prophylaxis dosing should be individually reviewed.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Riboflavin is not a pregnancy contraindication; higher-dose migraine use needs routine benefit-risk review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "NONE.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Warn the patient about the urine color change. Reassure them it is not liver failure or bleeding.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The 3-Month Rule", + "val": "Patients often quit Riboflavin after 2 weeks because their migraines haven't stopped. It takes 3 full months of 400mg daily to replenish mitochondrial enzymes in the brain. They must persist.", + "tags": [] + }, + { + "key": "The Cracked Lips", + "val": "Severe Riboflavin deficiency presents classically as 'Angular Cheilitis'—painful, cracked, bleeding sores at the corners of the mouth, combined with a magenta-colored tongue.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Precursor to flavin adenine dinucleotide (FAD) and flavin mononucleotide (FMN). Enhances mitochondrial energy efficiency in the brain, which is theorized to prevent the cortical spreading depression that causes migraines.", + "tags": [] + }, + { + "key": "Onset", + "val": "2-3 MONTHS for migraine prevention.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Hours. Excess is rapidly peed out.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health riboflavin nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Water-Soluble (B2) — Vitamin B2." + }, + { + "label": "Route / Formulation", + "value": "Tablets, Capsules. (Various OTC)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 400 mg **OD** (Requires 3 months of use to see efficacy). Max **400 mg/day** (For migraines)." + }, + { + "label": "Key Indication Doses", + "value": "Migraine Prophylaxis: **PO** 400 mg **OD** (Requires 3 months of use to see efficacy). Ariboflavinosis (Deficiency): **PO** 5-30 mg/day." + }, + { + "label": "Best Uses", + "value": "Riboflavin is used for migraine prophylaxis and riboflavin deficiency, but causes harmless bright yellow urine and has limited evidence for most supplementation claims." + }, + { + "label": "Avoid / Cautions", + "value": "NONE. Safe and highly recommended for migraine prophylaxis in pregnant women who cannot take standard preventative drugs." + }, + { + "label": "Key Risks", + "value": "Genitourinary: Intense neon-yellow discoloration of urine (Flavinuria). Harmless. Systemic: Virtually zero toxicity. Cannot overdose due to water solubility and limited gut absorption." + }, + { + "label": "Key Interactions", + "value": "NONE." + }, + { + "label": "Monitoring", + "value": "Warn the patient about the urine color change. Reassure them it is not liver failure or bleeding." + }, + { + "label": "Clinical Pearl", + "value": "Patients often quit Riboflavin after 2 weeks because their migraines haven't stopped. It takes 3 full months of 400mg daily to replenish mitochondrial enzymes in the brain. They must persist." + } + ] + }, + { + "slug": "selenium", + "name": "Selenium", + "class": "Mineral", + "subclass": "Trace Element", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "MINERAL", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "400 mcg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Toxicity", + "value": "GARLIC BREATH", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Hair Loss", + "value": "TOXICITY SIGN", + "cls": "hi", + "flag": "" + }, + { + "label": "Thyroid", + "value": "COFACTOR", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Trace mineral essential for glutathione peroxidase (antioxidant defense) and thyroid hormone conversion. Extremely toxic in overdose.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **400 mcg/day** (Toxic threshold). Normal dose is 50-100 mcg.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Selenium has a narrow therapeutic window: deficiency replacement is reasonable, but chronic excess causes selenosis with hair/nail changes, gastrointestinal symptoms, neuropathy, and garlic odour.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Selenium is an essential trace element for thyroid function and antioxidant defence, but has a narrow therapeutic window with toxicity (selenosis) causing hair loss, GI symptoms, and neuropathy.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Systemic", + "val": "CRITICAL — Selenosis: Brittle hair/nails that fall out, severe fatigue, GI distress, and 'garlic breath' (due to exhalation of dimethyl selenide).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Deficiency / TPN Additive", + "val": "**PO** or **IV** 50-100 mcg **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Various OTC", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Total Parenteral Nutrition (TPN) additive, Keshan disease, thyroid dysfunction support.", + "tags": ["TGA"] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Selenosis.", + "tags": [] + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "NONE — At standard doses.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "If a patient taking multiple 'health supplements' develops sudden hair loss and smells strongly of garlic, check their pill bottles for Selenium.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Brazil Nut Overdose", + "val": "A single Brazil nut contains ~90 mcg of Selenium. Eating just 5-6 Brazil nuts a day exceeds the toxic limit. Patients have presented to the ward with severe Selenosis purely from eating too many Brazil nuts.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Incorporated into selenoproteins. Essential for the deiodinase enzymes that convert T4 (inactive thyroid hormone) into T3 (active).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health selenium nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Trace Element — Trace mineral essential for glutathione peroxidase (antioxidant defense) and thyroid hormone conversion." + }, + { + "label": "Route / Formulation", + "value": "Tablets. (Various OTC)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** or **IV** 50-100 mcg **OD**. Max **400 mcg/day** (Toxic threshold). Normal dose is 50-100 mcg." + }, + { + "label": "Best Uses", + "value": "Selenium is an essential trace element for thyroid function and antioxidant defence, but has a narrow therapeutic window with toxicity (selenosis) causing hair loss, GI symptoms, and neuropathy." + }, + { + "label": "Avoid / Cautions", + "value": "Selenosis." + }, + { + "label": "Key Risks", + "value": "Systemic: Selenosis: Brittle hair/nails that fall out, severe fatigue, GI distress, and 'garlic breath' (due to exhalation of dimethyl selenide)." + }, + { + "label": "Key Interactions", + "value": "NONE — At standard doses." + }, + { + "label": "Monitoring", + "value": "If a patient taking multiple 'health supplements' develops sudden hair loss and smells strongly of garlic, check their pill bottles for Selenium." + }, + { + "label": "Clinical Pearl", + "value": "A single Brazil nut contains ~90 mcg of Selenium. Eating just 5-6 Brazil nuts a day exceeds the toxic limit. Patients have presented to the ward with severe Selenosis purely from eating too many Brazil nuts." + } + ] + }, + { + "slug": "sodium-chloride", + "name": "Sodium chloride", + "class": "Mineral", + "subclass": "Macromineral", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "MINERAL", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "Titrated", + "cls": "hi", + "flag": "hi" + }, + { + "label": "GI Ulceration", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Hyponatremia", + "value": "CHRONIC ONLY", + "cls": "good", + "flag": "" + }, + { + "label": "Heart Failure", + "value": "CONTRAIND.", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Oral salt tablets. Used to slowly correct chronic, asymptomatic hyponatremia. Highly irritating to the stomach.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Titrated entirely based on serum sodium levels (e.g., 2 to 6 tablets a day).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Never use oral salt tablets for acute, symptomatic hyponatremia (seizures/coma). That requires IV Hypertonic Saline in the ICU.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Sodium chloride is essential IV fluid for volume resuscitation and hyponatraemia correction, but excessive administration causes hyperchloraemic metabolic acidosis and overly rapid correction of hyponatraemia risks osmotic demyelination.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "CRITICAL — Severe nausea, vomiting, gastric ulceration. (Salt is intensely irritating to the gastric mucosa).", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Osmotic Demyelination Syndrome (ODS). If you raise the patient's blood sodium too fast (>8 mmol/L in 24 hours), their brainstem will shrink and demyelinate, causing permanent 'locked-in' paralysis.", + "tags": [] + }, + { + "key": "Cardiovascular", + "val": "HIGH — Fluid overload, acute pulmonary oedema (salt pulls water with it).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Chronic Hyponatremia / SIADH", + "val": "**PO** 1-2 tablets (600 mg each) **TDS**. Must be swallowed whole with a full glass of water.", + "tags": [] + }, + { + "key": "Post-Bowel Resection / Ileostomy", + "val": "**PO** Used to replace massive salt losses from high-output stomas.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Slow-Na", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Sustained-release tablets (600 mg = 10 mmol of Sodium).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Chronic sodium depletion, high-output stomas.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Used as an adjunct to fluid restriction in SIADH.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Avoid routine salt-tablet therapy in decompensated heart failure, severe cirrhosis with ascites, uncontrolled hypertension/oedema, or acute symptomatic hyponatraemia needing urgent hypertonic saline protocols.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "caution", + "severity": "danger", + "match": { + "hepatic": ["severe"] + }, + "note": "Salt-tablet therapy can worsen ascites/oedema in severe cirrhosis and needs specialist review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "HIGH — Antagonises the effect of all antihypertensives and diuretics.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Daily **U&E** (Sodium). Ensure the sodium is not rising faster than 8 mmol/L in any 24-hour period.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Look for the 'ghost pill' in the stool (wax matrix does not dissolve). Ensure patient takes it with a large meal.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Soup Alternative", + "val": "Because Slow-Na tablets frequently cause terrible vomiting, many physicians simply prescribe 'Bovril/Vegemite broth' or salty soups. These are far better tolerated by the stomach and provide massive amounts of oral sodium.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Provides elemental sodium and chloride. The slow-release wax matrix prevents a massive dump of salt into the stomach, mitigating (but not eliminating) vomiting.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to slowly raise serum levels.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Cleared by the kidneys under the control of Aldosterone.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health sodium nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Macromineral — Oral salt tablets." + }, + { + "label": "Route / Formulation", + "value": "Sustained-release tablets (600 mg = 10 mmol of Sodium). (Slow-Na)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1-2 tablets (600 mg each) **TDS**. Must be swallowed whole with a full glass of water. Titrated entirely based on serum sodium levels (e.g., 2 to 6 tablets a day)." + }, + { + "label": "Key Indication Doses", + "value": "Chronic Hyponatremia / SIADH: **PO** 1-2 tablets (600 mg each) **TDS**. Must be swallowed whole with a full glass of water. Post-Bowel Resection / Ileostomy: **PO** Used to replace massive salt losses from high-output stomas." + }, + { + "label": "Best Uses", + "value": "Sodium chloride is essential IV fluid for volume resuscitation and hyponatraemia correction, but excessive administration causes hyperchloraemic metabolic acidosis and overly rapid correction of hyponatraemia risks osmotic demyelination." + }, + { + "label": "Avoid / Cautions", + "value": "Congestive heart failure, severe liver cirrhosis with ascites, acute symptomatic hyponatremia." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Severe nausea, vomiting, gastric ulceration. (Salt is intensely irritating to the gastric mucosa). Neurological: Osmotic Demyelination Syndrome (ODS). If you raise the patient's blood sodium too fast (>8 mmol/L in 24 hours), their brainstem will shrink and demyelinate, causing permanent 'locked-in' paralysis. Cardiovascular: Fluid overload, acute pulmonary oedema (salt pulls water with it)." + }, + { + "label": "Key Interactions", + "value": "Antagonises the effect of all antihypertensives and diuretics." + }, + { + "label": "Monitoring", + "value": "Daily **U&E** (Sodium). Ensure the sodium is not rising faster than 8 mmol/L in any 24-hour period. Look for the 'ghost pill' in the stool (wax matrix does not dissolve). Ensure patient takes it with a large meal." + }, + { + "label": "Clinical Pearl", + "value": "Because Slow-Na tablets frequently cause terrible vomiting, many physicians simply prescribe 'Bovril/Vegemite broth' or salty soups. These are far better tolerated by the stomach and provide massive amounts of oral sodium." + } + ] + }, + { + "slug": "thiamine", + "name": "Thiamine", + "class": "Vitamin", + "subclass": "Water-Soluble (B1)", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "VITAMIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "1500 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Route", + "value": "IV or IM FIRST", + "cls": "purple", + "flag": "" + }, + { + "label": "Anaphylaxis", + "value": "IV RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Glucose", + "value": "GIVE AFTER", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Vitamin B1. Essential coenzyme for carbohydrate metabolism. The absolute critical, time-sensitive therapy to prevent Wernicke's Encephalopathy in alcoholics.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1500 mg/day** (500mg TDS IV for active Wernicke's).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "You MUST give Thiamine BEFORE administering any IV Glucose/Dextrose to a malnourished patient, or you will trigger irreversible brain damage.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Thiamine is essential for preventing and treating Wernicke's encephalopathy in alcohol use disorder, but must be given IV before any glucose administration to avoid precipitating irreversible brain damage.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Immunological", + "val": "HIGH — Anaphylaxis (Rare, but classically associated with rapid IV push of thiamine. Must be diluted and infused over 30 mins).", + "tags": [] + }, + { + "key": "Tissue", + "val": "MODERATE — Pain at injection site (**IM** injections are highly painful).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Active Wernicke's Encephalopathy", + "val": "**IV** 500 mg **TDS** in 100mL Normal Saline over 30 mins, for 3-5 days.", + "tags": [] + }, + { + "key": "Prophylaxis (Alcohol Withdrawal)", + "val": "**IM** / **IV** 300 mg **OD** for 3-5 days, then switch to oral.", + "tags": [] + }, + { + "key": "Oral Maintenance", + "val": "**PO** 100 mg **OD** to **TDS**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Betamin", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (100 mg).", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (100 mg/1 mL) for **IM** or **IV** infusion. Do NOT push fast IV.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (PO). Hospital supply (IV/IM).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention and treatment of Wernicke-Korsakoff syndrome in chronic alcoholism, severe malnutrition, hyperemesis gravidarum.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Emergency rescue therapy. Must be administered immediately upon presentation in susceptible patients.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Previous true anaphylaxis to IV thiamine.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE / INDICATED — Essential nutrient; give thiamine before carbohydrate/glucose in hyperemesis, malnutrition, or alcohol-use risk to prevent Wernicke encephalopathy.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Thiamine is pregnancy-compatible and may be indicated in hyperemesis or malnutrition risk." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "NONE — Safe to combine with all standard ward medications.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Bedside", + "val": "MANDATORY — Observe for 30 minutes during the first IV infusion for signs of anaphylaxis (wheeze, hypotension, rash).", + "tags": [] + }, + { + "key": "Neurological", + "val": "Assess for the classic Wernicke's triad: Confusion, Ataxia, Ophthalmoplegia (nystagmus/gaze palsy).", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Glucose Death Trap", + "val": "Glucose metabolism consumes Thiamine. If you give an alcoholic a bag of IV Dextrose or a high-carb meal *before* giving them Thiamine, you will consume their last remaining molecules of B1, plunging them into permanent Korsakoff's dementia. Thiamine FIRST, glucose SECOND.", + "tags": [] + }, + { + "key": "Oral is Useless", + "val": "In chronic alcoholics, the gut transporters for Thiamine are completely paralyzed by alcohol. Giving oral Thiamine in the first few days of admission is totally useless. They MUST have it **IM** or **IV** to bypass the gut.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Acts as a coenzyme in the metabolism of glucose (pyruvate dehydrogenase). Without it, neurons cannot utilize glucose for energy, leading to rapid neuronal death and lactic acidosis.", + "tags": [] + }, + { + "key": "Onset", + "val": "**IV** Immediate.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Rapidly cleared renally. Minimal body stores (depleted in 14 days of poor diet).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: Thiamine Hydrochloride Injection Australian CMI plus NHMRC/Eat For Health thiamin source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Water-Soluble (B1) — Vitamin B1." + }, + { + "label": "Route / Formulation", + "value": "Tablets (100 mg). (Betamin)" + }, + { + "label": "Usual Dose & Max", + "value": "**IV** 500 mg **TDS** in 100mL Normal Saline over 30 mins, for 3-5 days. Max **1500 mg/day** (500mg TDS IV for active Wernicke's)." + }, + { + "label": "Key Indication Doses", + "value": "Active Wernicke's Encephalopathy: **IV** 500 mg **TDS** in 100mL Normal Saline over 30 mins, for 3-5 days. Prophylaxis (Alcohol Withdrawal): **IM** / **IV** 300 mg **OD** for 3-5 days, then switch to oral. Oral Maintenance: **PO** 100 mg **OD** to **TDS**." + }, + { + "label": "Best Uses", + "value": "Thiamine is essential for preventing and treating Wernicke's encephalopathy in alcohol use disorder, but must be given IV before any glucose administration to avoid precipitating irreversible brain damage." + }, + { + "label": "Avoid / Cautions", + "value": "Previous true anaphylaxis to IV thiamine. Essential for hyperemesis gravidarum to prevent maternal Wernicke's." + }, + { + "label": "Key Risks", + "value": "Immunological: Anaphylaxis (Rare, but classically associated with rapid IV push of thiamine. Must be diluted and infused over 30 mins). Tissue: Pain at injection site (**IM** injections are highly painful)." + }, + { + "label": "Key Interactions", + "value": "NONE — Safe to combine with all standard ward medications." + }, + { + "label": "Monitoring", + "value": "Observe for 30 minutes during the first IV infusion for signs of anaphylaxis (wheeze, hypotension, rash). Assess for the classic Wernicke's triad: Confusion, Ataxia, Ophthalmoplegia (nystagmus/gaze palsy)." + }, + { + "label": "Clinical Pearl", + "value": "Glucose metabolism consumes Thiamine. If you give an alcoholic a bag of IV Dextrose or a high-carb meal *before* giving them Thiamine, you will consume their last remaining molecules of B1, plunging them into permanent Korsakoff's dementia. Thiamine FIRST, glucose SECOND." + } + ] + }, + { + "slug": "vitamin-a", + "name": "Vitamin A", + "class": "Vitamin", + "subclass": "Fat-Soluble", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "VITAMIN", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "3000 mcg RE/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "Months", + "cls": "", + "flag": "" + }, + { + "label": "Teratogenic", + "value": "CRITICAL", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Toxicity", + "value": "HEPATIC/CNS", + "cls": "hi", + "flag": "warn" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Essential fat-soluble vitamin. Crucial for vision (rhodopsin synthesis), immune function, and cellular differentiation. Stored in massive quantities in the liver.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Upper limit is **3000 mcg Retinol Equivalents (RE) / day**. Acute toxicity doses are much higher.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Highly teratogenic in excess. Pregnant women MUST avoid high-dose supplements and liver pate/liver meats.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Vitamin A is essential for vision, immunity, and skin health, but is teratogenic in high doses during pregnancy and chronic excess causes hepatotoxicity.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Neurological", + "val": "CRITICAL — Hypervitaminosis A causes benign intracranial hypertension (pseudotumor cerebri) presenting as severe headaches, blurred vision, and papilledema.", + "tags": [] + }, + { + "key": "Hepatic", + "val": "HIGH — Chronic excess causes hepatomegaly, cirrhosis, and fatal liver failure.", + "tags": [], + "patient": { + "factors": ["hepatic"], + "action": "dose-adjust", + "severity": "caution", + "note": "Inferred from existing decision-section wording; review before clinical use." + } + }, + { + "key": "Dermatological", + "val": "MODERATE — Dry, scaling skin, hair loss (alopecia), orange skin (carotenemia - harmless).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Deficiency (Xerophthalmia / Night Blindness)", + "val": "**PO** 200,000 IU daily for 2 days, repeated after 2 weeks (Specialist dosing, usually in developing nations or malabsorption syndromes).", + "tags": [] + }, + { + "key": "Maintenance / Cystic Fibrosis", + "val": "**PO** 10,000 IU **OD**.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Various OTC brands", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets. Usually formulated as Retinol or Beta-carotene.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention and treatment of Vitamin A deficiency, fat-malabsorption syndromes (CF, post-bariatric surgery), measles in pediatrics.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Deficiency is rare in Australia outside of severe malabsorption/alcoholism. Systemic retinoids (Isotretinoin) are used for acne.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Hypervitaminosis A, concurrent use of systemic retinoids (Roaccutane/Isotretinoin).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "CONTRAINDICATED / CAUTION — Avoid high-dose retinol vitamin A supplements and liver-derived high-retinol products in pregnancy; nutritional intake within recommended limits is required.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "contraindication", + "severity": "danger", + "note": "High-dose retinol vitamin A exposure is teratogenic; nutritional intake within recommended limits remains required." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Isotretinoin/Acitretin. These are Vitamin A derivatives. Adding Vitamin A supplements causes instant, severe systemic toxicity and intracranial hypertension.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Orlistat blocks absorption (fat-soluble).", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Monitor **LFTs** if on chronic high-dose therapy.", + "tags": [] + }, + { + "key": "Bedside", + "val": "Warn patients against taking 'mega-vitamins' alongside their normal multivitamin.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Polar Bear Liver", + "val": "A classic toxicology trivia fact: Polar bear and seal liver contains such phenomenally high concentrations of Vitamin A that eating it causes acute, fatal hypervitaminosis A. Warn pregnant patients against eating any animal liver/pate due to this high concentration.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Forms rhodopsin in the retina (required for low-light vision). Binds to Retinoic Acid Receptors (RAR) in the nucleus to control gene expression and epithelial turnover.", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Months. Stored entirely in hepatic stellate cells.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health vitamin A nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Fat-Soluble — Essential fat-soluble vitamin." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets. Usually formulated as Retinol or Beta-carotene. (Various OTC brands)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 200,000 IU daily for 2 days, repeated after 2 weeks (Specialist dosing, usually in developing nations or malabsorption syndromes). Upper limit is **3000 mcg Retinol Equivalents (RE) / day**. Acute toxicity doses are much higher." + }, + { + "label": "Key Indication Doses", + "value": "Severe Deficiency (Xerophthalmia / Night Blindness): **PO** 200,000 IU daily for 2 days, repeated after 2 weeks (Specialist dosing, usually in developing nations or malabsorption syndromes). Maintenance / Cystic Fibrosis: **PO** 10,000 IU **OD**." + }, + { + "label": "Best Uses", + "value": "Vitamin A is essential for vision, immunity, and skin health, but is teratogenic in high doses during pregnancy and chronic excess causes hepatotoxicity." + }, + { + "label": "Avoid / Cautions", + "value": "Hypervitaminosis A, concurrent use of systemic retinoids (Roaccutane/Isotretinoin). **Pregnancy** Category D (at doses > 10,000 IU). Causes severe craniofacial and cardiac birth defects." + }, + { + "label": "Key Risks", + "value": "Neurological: Hypervitaminosis A causes benign intracranial hypertension (pseudotumor cerebri) presenting as severe headaches, blurred vision, and papilledema. Hepatic: Chronic excess causes hepatomegaly, cirrhosis, and fatal liver failure. Dermatological: Dry, scaling skin, hair loss (alopecia), orange skin (carotenemia - harmless)." + }, + { + "label": "Key Interactions", + "value": "Isotretinoin/Acitretin. These are Vitamin A derivatives. Adding Vitamin A supplements causes instant, severe systemic toxicity and intracranial hypertension. Orlistat blocks absorption (fat-soluble)." + }, + { + "label": "Monitoring", + "value": "Monitor **LFTs** if on chronic high-dose therapy. Warn patients against taking 'mega-vitamins' alongside their normal multivitamin." + }, + { + "label": "Clinical Pearl", + "value": "A classic toxicology trivia fact: Polar bear and seal liver contains such phenomenally high concentrations of Vitamin A that eating it causes acute, fatal hypervitaminosis A. Warn pregnant patients against eating any animal liver/pate due to this high concentration." + } + ] + }, + { + "slug": "vitamin-b12", + "name": "Vitamin B12", + "class": "Vitamin", + "subclass": "Water-Soluble", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "VITAMIN", + "schedule": "S4", + "stats": [ + { + "label": "Target Level", + "value": "> 200 pmol/L", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Route", + "value": "IM or PO", + "cls": "purple", + "flag": "" + }, + { + "label": "Neuro Damage", + "value": "IRREVERSIBLE", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Storage", + "value": "HEPATIC", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Cobalamin. Essential water-soluble vitamin required for red blood cell formation and myelin sheath maintenance. The liver stores massive amounts, meaning deficiency takes years to develop.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1000 mcg (1 mg)** per injection.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Severe B12 deficiency causes subacute combined degeneration of the spinal cord. If not treated quickly, the neurological damage is completely irreversible.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Vitamin B12 is essential for treating megaloblastic anaemia and preventing irreversible neurological damage from deficiency, but IM loading is required for pernicious anaemia as oral absorption is impaired.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "HIGH — Hypokalemia. When you give B12 to a severely anemic patient, the bone marrow suddenly goes into overdrive making billions of new RBCs. The new cells pull massive amounts of potassium out of the blood, which can trigger fatal hypokalemia arrhythmias in the first 48 hours.", + "tags": [] + }, + { + "key": "Immunological", + "val": "LOW — Anaphylaxis to the IM injection (very rare).", + "tags": [] + }, + { + "key": "Dermatological", + "val": "LOW — Acne-like rash (transient).", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Pernicious Anemia / Severe Deficiency", + "val": "**IM** 1000 mcg 3 times a week for 2 weeks (Loading), then 1000 mcg every 3 months for life.", + "tags": [] + }, + { + "key": "Dietary Deficiency (Vegans)", + "val": "**PO** 1000 mcg **OD**.", + "tags": [] + }, + { + "key": "Neurological Involvement", + "val": "**IM** 1000 mcg on alternate days until symptoms stop improving, then every 2 months.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Neo-B12, Hydroxocobalamin, Cyanocobalamin", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (1000 mcg/1 mL) for deep **IM** injection. (Hydroxocobalamin is preferred as it stays in the body longer).", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Tablets (1000 mcg).", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (PO). General Benefit PBS (IM).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Pernicious anemia, post-gastrectomy, strict vegan diet deficiency, severe neuropathy.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "IM formulation is mandatory if the patient lacks Intrinsic Factor (Pernicious anemia), as oral absorption will be near zero.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Known hypersensitivity to cobalt or cobalamin.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A; replace deficiency promptly to protect maternal haematologic and neurologic function.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Vitamin B12 replacement is compatible with pregnancy and deficiency should be treated." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Metformin, PPIs (Pantoprazole), and Colchicine physically block the absorption of oral B12 in the terminal ileum. Patients on long-term Metformin/PPIs frequently become deficient and require IM replacement.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Monitor **U&E** (Potassium) strictly during the first week of intensive IM loading in severe anemia.", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Check **FBC** (MCV should normalize) and Reticulocyte count.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Laughing Gas Trap", + "val": "Nitrous Oxide (used in anaesthesia and recreationally abused in 'nangs') irreversibly oxidises the cobalt atom in Vitamin B12, completely destroying it. Severe nitrous abuse causes instant, profound B12-deficiency paralysis and spinal cord degeneration.", + "tags": [] + }, + { + "key": "The Cyanide Antidote", + "val": "Massive doses of IV Hydroxocobalamin (Cyanokit - 5 grams IV) are the direct emergency antidote for Cyanide poisoning (e.g., house fires, sodium nitroprusside toxicity). It binds the cyanide to form harmless cyanocobalamin, which is peed out.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Acts as a coenzyme for methylmalonyl-CoA mutase and methionine synthase. Required for DNA synthesis, hematopoiesis, and maintenance of myelin.", + "tags": [] + }, + { + "key": "Onset", + "val": "Reticulocyte response in 3-5 days. Neurological recovery takes months.", + "tags": [] + }, + { + "key": "Half-life", + "val": "The liver stores a 3-5 year supply. Highly conserved via enterohepatic recycling.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NEO-B12 and NHMRC/Eat For Health vitamin B12 source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Water-Soluble — Cobalamin." + }, + { + "label": "Route / Formulation", + "value": "Ampoules (1000 mcg/1 mL) for deep **IM** injection. (Hydroxocobalamin is preferred as it stays in the body longer). (Neo-B12, Hydroxocobalamin, Cyanocobalamin)" + }, + { + "label": "Usual Dose & Max", + "value": "**IM** 1000 mcg 3 times a week for 2 weeks (Loading), then 1000 mcg every 3 months for life. Max **1000 mcg (1 mg)** per injection." + }, + { + "label": "Key Indication Doses", + "value": "Pernicious Anemia / Severe Deficiency: **IM** 1000 mcg 3 times a week for 2 weeks (Loading), then 1000 mcg every 3 months for life. Dietary Deficiency (Vegans): **PO** 1000 mcg **OD**. Neurological Involvement: **IM** 1000 mcg on alternate days until symptoms stop improving, then every 2 months." + }, + { + "label": "Best Uses", + "value": "Vitamin B12 is essential for treating megaloblastic anaemia and preventing irreversible neurological damage from deficiency, but IM loading is required for pernicious anaemia as oral absorption is impaired." + }, + { + "label": "Avoid / Cautions", + "value": "Known hypersensitivity to cobalt or cobalamin. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Metabolic: Hypokalemia. When you give B12 to a severely anemic patient, the bone marrow suddenly goes into overdrive making billions of new RBCs. The new cells pull massive amounts of potassium out of the blood, which can trigger fatal hypokalemia arrhythmias in the first 48 hours. Immunological: Anaphylaxis to the IM injection (very rare). Dermatological: Acne-like rash (transient)." + }, + { + "label": "Key Interactions", + "value": "Metformin, PPIs (Pantoprazole), and Colchicine physically block the absorption of oral B12 in the terminal ileum. Patients on long-term Metformin/PPIs frequently become deficient and require IM replacement." + }, + { + "label": "Monitoring", + "value": "Monitor **U&E** (Potassium) strictly during the first week of intensive IM loading in severe anemia. Check **FBC** (MCV should normalize) and Reticulocyte count." + }, + { + "label": "Clinical Pearl", + "value": "Nitrous Oxide (used in anaesthesia and recreationally abused in 'nangs') irreversibly oxidises the cobalt atom in Vitamin B12, completely destroying it. Severe nitrous abuse causes instant, profound B12-deficiency paralysis and spinal cord degeneration." + } + ] + }, + { + "slug": "vitamin-d", + "name": "Vitamin D", + "class": "Vitamin", + "subclass": "Fat-Soluble", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "VITAMIN", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Target Level", + "value": "> 50 nmol/L", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "3-6 WEEKS", + "cls": "", + "flag": "" + }, + { + "label": "Toxicity", + "value": "RARE", + "cls": "good", + "flag": "" + }, + { + "label": "Hypercalcemia", + "value": "RISK", + "cls": "warn", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Colecalciferol (Vitamin D3). Essential fat-soluble vitamin. Acts as a hormone to regulate calcium and phosphate homeostasis, ensuring bone mineralization and immune function.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **4000 IU/day** (maintenance). Acute loading doses up to 500,000 IU total over weeks.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Purely taking calcium supplements without adequate Vitamin D is useless, as Vitamin D is required to actively absorb calcium from the gut.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Vitamin D is essential supplementation for bone health, calcium absorption, and deficiency states, but toxicity causes dangerous hypercalcaemia and should be monitored if high-dose therapy is used.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Metabolic", + "val": "HIGH — Hypercalcemia and Hyperphosphatemia (only occurs with massive accidental overdose).", + "tags": [] + }, + { + "key": "Renal", + "val": "MODERATE — Hypercalciuria leading to calcium kidney stones (if overdosed).", + "tags": [] + }, + { + "key": "Gastrointestinal", + "val": "LOW — Constipation, nausea.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Severe Deficiency (< 25 nmol/L)", + "val": "**PO** 50,000 IU once weekly for 8 weeks (Loading), then switch to maintenance.", + "tags": [] + }, + { + "key": "Maintenance Prophylaxis", + "val": "**PO** 1000 IU **OD** (or 1 capsule of 7000 IU once weekly for convenience).", + "tags": [] + }, + { + "key": "Renal Failure (Specialist)", + "val": "MANDATORY — Standard Colecalciferol is useless in severe CKD because the kidneys cannot hydroxylate it to the active form. Must prescribe Calcitriol (active Vitamin D).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Ostelin, Osteavit", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets (1000 IU, 7000 IU). Oral liquid.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC). High strength requires prescription.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Prevention and treatment of Vitamin D deficiency, adjunct to osteoporosis therapy.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Mandatory co-prescription with all bisphosphonates (Alendronate) and RANKL inhibitors (Denosumab) to prevent severe hypocalcemia.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Pre-existing hypercalcemia, hypervitaminosis D, metastatic bone disease causing high calcium.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A at recommended replacement doses; keep dosing within recommended replacement ranges because excessive intake can cause hypercalcaemia.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Vitamin D replacement is compatible with pregnancy when kept within recommended dosing." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "HIGH — Orlistat and Bile Acid Sequestrants block the absorption of all fat-soluble vitamins (A, D, E, K). Separate doses by 2-4 hours.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "MODERATE — Phenytoin and Carbamazepine accelerate Vitamin D metabolism, increasing the dose requirement.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Measure serum 25-OH-Vitamin D. Do not re-check levels earlier than 3 months after starting therapy (takes months to reach steady state).", + "tags": [] + }, + { + "key": "Laboratory", + "val": "Monitor Calcium and **U&E**.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Bone Trap", + "val": "Never start Denosumab (Prolia) or a Zoledronic acid infusion without confirming the patient has a normal Vitamin D level. If they are deficient, the drugs will strip the blood of calcium, causing a lethal hypocalcemic crash.", + "tags": [] + }, + { + "key": "Fat Soluble Fact", + "val": "Because it is fat-soluble, it requires dietary fat for optimal absorption. Tell the patient to take it with their heaviest meal (e.g., dinner or a glass of full-cream milk).", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Colecalciferol (D3) is hydroxylated in the liver to 25(OH)D, then hydroxylated in the kidneys to the active 1,25-dihydroxycholecalciferol (Calcitriol). It binds to nuclear receptors in the gut to massively upregulate calcium absorption.", + "tags": [] + }, + { + "key": "Onset", + "val": "Weeks to normalize blood levels.", + "tags": [] + }, + { + "key": "Half-life", + "val": "3-6 WEEKS (Stored efficiently in adipose tissue).", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health vitamin D nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Fat-Soluble — Colecalciferol (Vitamin D3)." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets (1000 IU, 7000 IU). Oral liquid. (Ostelin, Osteavit)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 50,000 IU once weekly for 8 weeks (Loading), then switch to maintenance. Max **4000 IU/day** (maintenance). Acute loading doses up to 500,000 IU total over weeks." + }, + { + "label": "Key Indication Doses", + "value": "Severe Deficiency (< 25 nmol/L): **PO** 50,000 IU once weekly for 8 weeks (Loading), then switch to maintenance. Maintenance Prophylaxis: **PO** 1000 IU **OD** (or 1 capsule of 7000 IU once weekly for convenience). Renal Failure (Specialist): Standard Colecalciferol is useless in severe CKD because the kidneys cannot hydroxylate it to the active form. Must prescribe Calcitriol (active Vitamin D)." + }, + { + "label": "Best Uses", + "value": "Vitamin D is essential supplementation for bone health, calcium absorption, and deficiency states, but toxicity causes dangerous hypercalcaemia and should be monitored if high-dose therapy is used." + }, + { + "label": "Avoid / Cautions", + "value": "Pre-existing hypercalcemia, hypervitaminosis D, metastatic bone disease causing high calcium. **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Metabolic: Hypercalcemia and Hyperphosphatemia (only occurs with massive accidental overdose). Renal: Hypercalciuria leading to calcium kidney stones (if overdosed). Gastrointestinal: Constipation, nausea." + }, + { + "label": "Key Interactions", + "value": "Orlistat and Bile Acid Sequestrants block the absorption of all fat-soluble vitamins (A, D, E, K). Separate doses by 2-4 hours. Phenytoin and Carbamazepine accelerate Vitamin D metabolism, increasing the dose requirement." + }, + { + "label": "Monitoring", + "value": "Measure serum 25-OH-Vitamin D. Do not re-check levels earlier than 3 months after starting therapy (takes months to reach steady state). Monitor Calcium and **U&E**." + }, + { + "label": "Clinical Pearl", + "value": "Never start Denosumab (Prolia) or a Zoledronic acid infusion without confirming the patient has a normal Vitamin D level. If they are deficient, the drugs will strip the blood of calcium, causing a lethal hypocalcemic crash." + } + ] + }, + { + "slug": "vitamin-e", + "name": "Vitamin E", + "class": "Vitamin", + "subclass": "Fat-Soluble", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "VITAMIN", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "1000 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Half-life", + "value": "Weeks", + "cls": "", + "flag": "" + }, + { + "label": "Bleeding", + "value": "HIGH RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Malabsorption", + "value": "INDICATED", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Fat-soluble antioxidant (Tocopherol). Protects cell membranes from oxidative damage. Rarely deficient except in severe fat malabsorption syndromes (e.g., Cystic Fibrosis).", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **1000 mg/day** (High doses increase all-cause mortality).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "High doses (>400 IU/day) strongly interfere with Vitamin K, significantly increasing the risk of bleeding and hemorrhagic stroke.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Vitamin E is a fat-soluble antioxidant sometimes used for deficiency states and NAFLD, but high-dose supplementation may increase all-cause mortality and bleeding risk with anticoagulants.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Haematological", + "val": "CRITICAL — Coagulopathy and bleeding. High doses inhibit Vitamin K-dependent clotting factors.", + "tags": [] + }, + { + "key": "Systemic", + "val": "HIGH — Meta-analyses show increased all-cause mortality and increased risk of prostate cancer at chronic doses > 400 IU/day.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Malabsorption / Cystic Fibrosis", + "val": "**PO** 100-400 IU **OD**.", + "tags": [] + }, + { + "key": "NASH (Non-Alcoholic Steatohepatitis)", + "val": "**PO** 800 IU **OD** (Off-label specialist use).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Various OTC", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Treatment of Vitamin E deficiency.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Routine supplementation in healthy adults is actively discouraged due to lack of benefit and increased mortality signals in large trials (HOPE/SELECT trials).", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — Bleeding disorders, upcoming surgery.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — Normal dietary vitamin E intake is compatible with pregnancy; use high-dose supplementation only when deficiency or specialist indication is confirmed.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Normal vitamin E intake is pregnancy-compatible; high-dose supplementation needs review." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Warfarin, DOACs, Aspirin. High-dose Vitamin E acts as a blood thinner and will synergistically increase the risk of fatal hemorrhage.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "Monitor **INR** closely if the patient is on Warfarin and decides to start taking Vitamin E supplements.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Antioxidant Myth", + "val": "In the 1990s, high-dose Vitamin E was heavily pushed to prevent heart attacks and cancer. Massive randomized trials eventually proved it did the exact opposite—increasing strokes and prostate cancer. Advise patients to stop taking 'mega-doses' unless treating a diagnosed deficiency.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Scavenges free radicals, preventing lipid peroxidation of polyunsaturated fatty acids in cell membranes.", + "tags": [] + }, + { + "key": "Onset", + "val": "Weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Weeks. Stored in adipose tissue.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health vitamin E nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Fat-Soluble — Fat-soluble antioxidant (Tocopherol)." + }, + { + "label": "Route / Formulation", + "value": "Capsules. (Various OTC)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 100-400 IU **OD**. Max **1000 mg/day** (High doses increase all-cause mortality)." + }, + { + "label": "Key Indication Doses", + "value": "Malabsorption / Cystic Fibrosis: **PO** 100-400 IU **OD**. NASH (Non-Alcoholic Steatohepatitis): **PO** 800 IU **OD** (Off-label specialist use)." + }, + { + "label": "Best Uses", + "value": "Vitamin E is a fat-soluble antioxidant sometimes used for deficiency states and NAFLD, but high-dose supplementation may increase all-cause mortality and bleeding risk with anticoagulants." + }, + { + "label": "Avoid / Cautions", + "value": "Bleeding disorders, upcoming surgery. At normal dietary doses." + }, + { + "label": "Key Risks", + "value": "Haematological: Coagulopathy and bleeding. High doses inhibit Vitamin K-dependent clotting factors. Systemic: Meta-analyses show increased all-cause mortality and increased risk of prostate cancer at chronic doses > 400 IU/day." + }, + { + "label": "Key Interactions", + "value": "Warfarin, DOACs, Aspirin. High-dose Vitamin E acts as a blood thinner and will synergistically increase the risk of fatal hemorrhage." + }, + { + "label": "Monitoring", + "value": "Monitor **INR** closely if the patient is on Warfarin and decides to start taking Vitamin E supplements." + }, + { + "label": "Clinical Pearl", + "value": "In the 1990s, high-dose Vitamin E was heavily pushed to prevent heart attacks and cancer. Massive randomized trials eventually proved it did the exact opposite—increasing strokes and prostate cancer. Advise patients to stop taking 'mega-doses' unless treating a diagnosed deficiency." + } + ] + }, + { + "slug": "vitamin-k", + "name": "Vitamin K", + "class": "Vitamin", + "subclass": "Fat-Soluble", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "VITAMIN", + "schedule": "S4", + "stats": [ + { + "label": "Max Dose", + "value": "10 mg (STAT)", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Onset", + "value": "6-24 h", + "cls": "", + "flag": "" + }, + { + "label": "Anaphylaxis", + "value": "IV RISK", + "cls": "hi", + "flag": "warn" + }, + { + "label": "Route", + "value": "PO or IV", + "cls": "purple", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Phytomenadione. Essential cofactor for the hepatic synthesis of clotting factors II, VII, IX, and X. The definitive antidote for Warfarin overdose/toxicity.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **10 mg** (STAT) for severe bleeding on Warfarin.", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "IV Vitamin K carries a rare but severe 'black box' risk of anaphylaxis. Must be run slowly. SC/IM routes are erratic and should be avoided.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Vitamin K is essential for reversing warfarin over-anticoagulation and treating haemorrhagic disease of the newborn, but IV administration carries rare anaphylaxis risk and takes 6-12 hours for full effect.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Immunological", + "val": "CRITICAL — Severe anaphylactoid reaction, shock, and cardiac arrest associated with rapid **IV** bolus. (Caused by the polyethoxylated castor oil suspension vehicle, not the vitamin itself).", + "tags": [] + }, + { + "key": "Haematological", + "val": "HIGH — Re-starting Warfarin is incredibly difficult for 1-2 weeks after a large dose (10 mg) of Vitamin K, leaving the patient exposed to clotting risks.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Warfarin Reversal (Minor bleed / High INR)", + "val": "**PO** 1-3 mg STAT. Recheck INR in 24 hours.", + "tags": [] + }, + { + "key": "Warfarin Reversal (Major Bleeding)", + "val": "**IV** 5-10 mg STAT (diluted in 50mL glucose/saline, run over 30 mins) PLUS Prothrombinex-VF.", + "tags": [] + }, + { + "key": "Neonatal Prophylaxis", + "val": "**IM** 1 mg STAT immediately after birth to prevent Haemorrhagic Disease of the Newborn.", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Konakion MM", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "The IV ampoule liquid (Konakion MM) can be drawn up in a syringe and given orally.", + "tags": [] + }, + { + "key": "Parenteral", + "val": "Ampoules (10 mg/1 mL) for **IV** infusion or oral administration. Ampoules (2 mg/0.2 mL) for paediatric **IM**.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Hospital supply. S4.", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Warfarin reversal, severe liver disease coagulopathy, Vitamin K deficiency bleeding in neonates.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Mandatory antidote for supratherapeutic INRs. Takes time to work; not an instant fix.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "CRITICAL — DOAC Reversal. Vitamin K is completely useless for reversing Rivaroxaban or Apixaban (they do not rely on Vitamin K).", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — **Pregnancy** Category A when clinically indicated; use route and dose based on warfarin reversal, deficiency, or neonatal prophylaxis context.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Vitamin K is not a pregnancy contraindication when clinically indicated." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacodynamic", + "val": "CRITICAL — Warfarin. Vitamin K directly antagonises it.", + "tags": [] + }, + { + "key": "Pharmacokinetic", + "val": "HIGH — Bile acid sequestrants (Cholestyramine) and Orlistat block fat-soluble vitamin absorption in the gut. Avoid giving PO Vitamin K with them.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — Monitor **INR** 6-12 hours after IV administration, or 24 hours after oral administration.", + "tags": [] + }, + { + "key": "Bedside", + "val": "MANDATORY — Infuse IV formulations slowly (over at least 30 mins) while monitoring **BP** and **HR** to prevent anaphylactoid shock.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Subcut Trap", + "val": "Never give Vitamin K subcutaneously (**SC**). In a shocked or bleeding patient, SC tissue shuts down. The drug will sit in the fat and do absolutely nothing. Use **PO** or **IV**.", + "tags": [] + }, + { + "key": "Prothrombinex Required", + "val": "If a patient is actively bleeding into their brain or gut on Warfarin, Vitamin K alone will not save them. It takes the liver 12 hours to build new clotting factors. You MUST give Prothrombinex-VF (instant clotting factors) alongside the IV Vitamin K.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Promotes the gamma-carboxylation of glutamic acid residues on precursor clotting factors, rendering them active. Competes directly with Warfarin at the VKORC1 enzyme.", + "tags": [] + }, + { + "key": "Onset", + "val": "**PO** 24 hours. **IV** 6-12 hours.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Rapidly cleared, but the newly synthesized clotting factors last for days.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: KONAKION MM phytomenadione Australian CMI source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Fat-Soluble — Phytomenadione." + }, + { + "label": "Route / Formulation", + "value": "The IV ampoule liquid (Konakion MM) can be drawn up in a syringe and given orally. (Konakion MM)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 1-3 mg STAT. Recheck INR in 24 hours. Max **10 mg** (STAT) for severe bleeding on Warfarin." + }, + { + "label": "Key Indication Doses", + "value": "Warfarin Reversal (Minor bleed / High INR): **PO** 1-3 mg STAT. Recheck INR in 24 hours. Warfarin Reversal (Major Bleeding): **IV** 5-10 mg STAT (diluted in 50mL glucose/saline, run over 30 mins) PLUS Prothrombinex-VF. Neonatal Prophylaxis: **IM** 1 mg STAT immediately after birth to prevent Haemorrhagic Disease of the Newborn." + }, + { + "label": "Best Uses", + "value": "Vitamin K is essential for reversing warfarin over-anticoagulation and treating haemorrhagic disease of the newborn, but IV administration carries rare anaphylaxis risk and takes 6-12 hours for full effect." + }, + { + "label": "Avoid / Cautions", + "value": "DOAC Reversal. Vitamin K is completely useless for reversing Rivaroxaban or Apixaban (they do not rely on Vitamin K). **Pregnancy** Category A." + }, + { + "label": "Key Risks", + "value": "Immunological: Severe anaphylactoid reaction, shock, and cardiac arrest associated with rapid **IV** bolus. (Caused by the polyethoxylated castor oil suspension vehicle, not the vitamin itself). Haematological: Re-starting Warfarin is incredibly difficult for 1-2 weeks after a large dose (10 mg) of Vitamin K, leaving the patient exposed to clotting risks." + }, + { + "label": "Key Interactions", + "value": "Warfarin. Vitamin K directly antagonises it. Bile acid sequestrants (Cholestyramine) and Orlistat block fat-soluble vitamin absorption in the gut. Avoid giving PO Vitamin K with them." + }, + { + "label": "Monitoring", + "value": "Monitor **INR** 6-12 hours after IV administration, or 24 hours after oral administration. Infuse IV formulations slowly (over at least 30 mins) while monitoring **BP** and **HR** to prevent anaphylactoid shock." + }, + { + "label": "Clinical Pearl", + "value": "Never give Vitamin K subcutaneously (**SC**). In a shocked or bleeding patient, SC tissue shuts down. The drug will sit in the fat and do absolutely nothing. Use **PO** or **IV**." + } + ] + }, + { + "slug": "zinc-sulfate", + "name": "Zinc sulfate", + "class": "Mineral", + "subclass": "Trace Element", + "category": "Vitamins & Minerals", + "accent": "#0891b2", + "tag": "MINERAL", + "schedule": "UNSCHEDULED", + "stats": [ + { + "label": "Max Dose", + "value": "220 mg/day", + "cls": "hi", + "flag": "hi" + }, + { + "label": "Copper Defic.", + "value": "CHRONIC RISK", + "cls": "warn", + "flag": "warn" + }, + { + "label": "Nausea", + "value": "SEVERE (EMPTY STOMACH)", + "cls": "warn", + "flag": "" + }, + { + "label": "Wound Healing", + "value": "INDICATED", + "cls": "good", + "flag": "" + } + ], + "sections": [ + { + "title": "Rapid Summary", + "type": "summary", + "rows": [ + { + "key": "Overview", + "val": "Essential trace element required for over 300 metalloenzymes, DNA synthesis, and immune function. Critical for severe wound healing.", + "tags": [] + }, + { + "key": "Maximum Dose", + "val": "Max **220 mg/day** (equivalent to 50 mg elemental zinc).", + "tags": [] + }, + { + "key": "Clinical Focus", + "val": "Long-term high-dose zinc severely blocks Copper absorption, causing irreversible neurological damage from copper deficiency.", + "tags": [] + }, + { + "key": "Bottom Line", + "val": "Zinc sulfate is used for zinc deficiency, wound healing support, and acute diarrhoea in children, but causes significant nausea on an empty stomach and copper deficiency with chronic use.", + "tags": [] + } + ] + }, + { + "title": "Risk Profile", + "type": "risk", + "rows": [ + { + "key": "Gastrointestinal", + "val": "HIGH — Intense nausea, vomiting, metallic taste (almost guaranteed if taken on an empty stomach).", + "tags": [] + }, + { + "key": "Neurological", + "val": "CRITICAL — Copper deficiency myeloneuropathy (mimics B12 deficiency paralysis) if used chronically at high doses.", + "tags": [] + } + ] + }, + { + "title": "Dosing & Administration", + "type": "dose", + "rows": [ + { + "key": "Zinc Deficiency / Wound Healing", + "val": "**PO** 220 mg (50 mg elemental) **OD** or **BD**. Take with food to prevent severe nausea.", + "tags": [] + }, + { + "key": "Wilson's Disease (Maintenance)", + "val": "**PO** 50 mg elemental **TDS** (Acts to block copper absorption).", + "tags": [] + } + ] + }, + { + "title": "Formulation & Access", + "type": "form", + "rows": [ + { + "key": "Brand Names", + "val": "Zincaps", + "tags": [] + }, + { + "key": "Oral Routes", + "val": "Capsules/Tablets. Effervescent tablets.", + "tags": [] + }, + { + "key": "Prescribing & PBS", + "val": "Over The Counter (OTC).", + "tags": [] + } + ] + }, + { + "title": "Indications & Use", + "type": "ind", + "rows": [ + { + "key": "Primary", + "val": "Zinc deficiency, severe burns, massive pressure ulcers, Wilson's disease.", + "tags": ["TGA"] + }, + { + "key": "Clinical Place", + "val": "Routinely added to the drug chart of ICU or geriatric patients with massive, non-healing bedsores to fuel collagen synthesis.", + "tags": [] + } + ] + }, + { + "title": "Contraindications & Populations", + "type": "contra", + "rows": [ + { + "key": "Absolute", + "val": "NONE — In acute deficiency.", + "tags": [] + }, + { + "key": "Pregnancy", + "val": "SAFE — Essential nutrient at recommended intake/replacement doses; reserve prolonged high-dose zinc for documented deficiency and monitor copper status.", + "tags": [], + "patient": { + "factors": ["pregnancy"], + "action": "info", + "severity": "info", + "note": "Zinc is pregnancy-compatible at recommended doses; prolonged high-dose therapy needs copper monitoring." + } + } + ] + }, + { + "title": "Key Interactions", + "type": "inter", + "rows": [ + { + "key": "Pharmacokinetic", + "val": "CRITICAL — Binds and destroys the absorption of Tetracyclines (Doxycycline) and Fluoroquinolones (Ciprofloxacin). Separate by 4 hours.", + "tags": [] + } + ] + }, + { + "title": "Monitoring & Cautions", + "type": "mon", + "rows": [ + { + "key": "Laboratory", + "val": "MANDATORY — If keeping a patient on Zinc for > 3 months, you MUST check Serum Copper levels to prevent irreversible neuropathy.", + "tags": [] + } + ] + }, + { + "title": "Clinical Pearls", + "type": "pearl", + "rows": [ + { + "key": "The Iron Clash", + "val": "Zinc and Iron compete for the exact same transporter in the gut. If you give a patient Zincaps and Ferro-gradumet at the same time, neither will absorb properly. Take them at different times of the day.", + "tags": [] + } + ] + }, + { + "title": "Mechanism & Pharmacokinetics", + "type": "evid", + "rows": [ + { + "key": "Mechanism", + "val": "Cofactor for collagenase and DNA/RNA polymerases. In the gut, it induces metallothionein in enterocytes, which binds copper tightly, preventing copper from entering the blood (exploited in Wilson's disease).", + "tags": [] + }, + { + "key": "Onset", + "val": "Days to weeks.", + "tags": [] + }, + { + "key": "Half-life", + "val": "Excreted primarily in feces.", + "tags": [] + } + ] + }, + { + "title": "Sources", + "type": "src", + "rows": [ + { + "key": "Source Review", + "val": "Source-backed review 2026-05-12: NHMRC/Eat For Health zinc nutrient reference source pack. Entry checked for dosing, access, contraindications/populations, interactions, monitoring, patient-context metadata, and app structure." + } + ] + } + ], + "quick": [ + { + "label": "Class & Role", + "value": "Trace Element — Essential trace element required for over 300 metalloenzymes, DNA synthesis, and immune function." + }, + { + "label": "Route / Formulation", + "value": "Capsules/Tablets. Effervescent tablets. (Zincaps)" + }, + { + "label": "Usual Dose & Max", + "value": "**PO** 220 mg (50 mg elemental) **OD** or **BD**. Take with food to prevent severe nausea. Max **220 mg/day** (equivalent to 50 mg elemental zinc)." + }, + { + "label": "Key Indication Doses", + "value": "Zinc Deficiency / Wound Healing: **PO** 220 mg (50 mg elemental) **OD** or **BD**. Take with food to prevent severe nausea. Wilson's Disease (Maintenance): **PO** 50 mg elemental **TDS** (Acts to block copper absorption)." + }, + { + "label": "Best Uses", + "value": "Zinc sulfate is used for zinc deficiency, wound healing support, and acute diarrhoea in children, but causes significant nausea on an empty stomach and copper deficiency with chronic use." + }, + { + "label": "Avoid / Cautions", + "value": "NONE — In acute deficiency. Essential nutrient." + }, + { + "label": "Key Risks", + "value": "Gastrointestinal: Intense nausea, vomiting, metallic taste (almost guaranteed if taken on an empty stomach). Neurological: Copper deficiency myeloneuropathy (mimics B12 deficiency paralysis) if used chronically at high doses." + }, + { + "label": "Key Interactions", + "value": "Binds and destroys the absorption of Tetracyclines (Doxycycline) and Fluoroquinolones (Ciprofloxacin). Separate by 4 hours." + }, + { + "label": "Monitoring", + "value": "If keeping a patient on Zinc for > 3 months, you MUST check Serum Copper levels to prevent irreversible neuropathy." + }, + { + "label": "Clinical Pearl", + "value": "Zinc and Iron compete for the exact same transporter in the gut. If you give a patient Zincaps and Ferro-gradumet at the same time, neither will absorb properly. Take them at different times of the day." + } + ] + } +] diff --git a/src/app/api/medications/[slug]/route.ts b/src/app/api/medications/[slug]/route.ts new file mode 100644 index 000000000..51c08d061 --- /dev/null +++ b/src/app/api/medications/[slug]/route.ts @@ -0,0 +1,49 @@ +import { NextResponse } from "next/server"; + +import { isDemoMode, isLocalNoAuthMode } from "@/lib/env"; +import { jsonError } from "@/lib/http"; +import { getMedicationRecord } from "@/lib/medication-snapshot"; +import { deriveGovernanceFromSections, normalizeMedicationSlug } from "@/lib/medication-records"; + +export const runtime = "nodejs"; + +function medicationResponse(payload: Record, init?: { status?: number }) { + return NextResponse.json(payload, { + status: init?.status ?? 200, + headers: { "Cache-Control": "private, no-store" }, + }); +} + +function notFoundResponse(slug: string) { + return medicationResponse({ error: `No medication found for "${slug}".` }, { status: 404 }); +} + +function publicMedicationDetailPayload(slug: string) { + const record = getMedicationRecord(slug); + if (!record) return null; + const governance = deriveGovernanceFromSections(record); + return { + record, + governance: { + sourceStatus: governance.source_status, + validationStatus: governance.validation_status, + }, + }; +} + +export async function GET(_request: Request, context: { params: Promise<{ slug: string }> }) { + try { + const { slug } = await context.params; + const normalizedSlug = normalizeMedicationSlug(slug); + const payload = publicMedicationDetailPayload(normalizedSlug); + if (!payload) return notFoundResponse(normalizedSlug); + + return medicationResponse({ + ...payload, + demoMode: isDemoMode() || isLocalNoAuthMode(), + publicAccess: true, + }); + } catch (error) { + return jsonError(error); + } +} diff --git a/src/app/api/medications/route.ts b/src/app/api/medications/route.ts new file mode 100644 index 000000000..3187f764e --- /dev/null +++ b/src/app/api/medications/route.ts @@ -0,0 +1,90 @@ +import { NextResponse } from "next/server"; +import { z } from "zod"; + +import { isDemoMode, isLocalNoAuthMode } from "@/lib/env"; +import { jsonError } from "@/lib/http"; +import { defaultMedicationRecords } from "@/lib/medication-seed"; +import { medicationSourceStatus, medicationValidationStatus } from "@/lib/medication-records"; +import { + medicationToSearchResult, + rankMedicationRecords, + type MedicationRecord, + type MedicationSearchMatch, +} from "@/lib/medications"; +import { parseRequestQuery, queryInteger } from "@/lib/validation/query"; + +export const runtime = "nodejs"; + +const medicationListQuerySchema = z.object({ + q: z + .string() + .trim() + .max(200) + .optional() + .transform((value) => (value ? value : undefined)), + limit: queryInteger({ fallback: 50, min: 1, max: 100 }), + fields: z.enum(["index"]).optional(), +}); + +function toIndexRecords(records: MedicationRecord[]): MedicationRecord[] { + return records.map((record) => ({ + slug: record.slug, + name: record.name, + class: record.class, + subclass: record.subclass, + category: record.category, + accent: record.accent, + tag: record.tag, + schedule: record.schedule, + stats: [], + sections: [], + quick: [], + })); +} + +function medicationResponse(payload: Record) { + return NextResponse.json(payload, { headers: { "Cache-Control": "private, no-store" } }); +} + +function matchesPayload(matches: MedicationSearchMatch[]) { + return matches.map((match) => ({ + medication: match.medication, + result: medicationToSearchResult(match), + score: match.score, + reasons: match.reasons, + })); +} + +function publicMedicationPayload(q: string | undefined, limit: number, fields?: "index") { + const records = fields === "index" ? toIndexRecords(defaultMedicationRecords()) : defaultMedicationRecords(); + const governance = Object.fromEntries( + records.map((record) => [ + record.slug, + { + sourceStatus: medicationSourceStatus("current"), + validationStatus: medicationValidationStatus("locally_reviewed"), + }, + ]), + ); + const matches = q ? rankMedicationRecords(records, q, limit) : undefined; + return { + records, + matches: matches ? matchesPayload(matches) : undefined, + total: records.length, + governance, + }; +} + +export async function GET(request: Request) { + try { + const { q, limit, fields } = parseRequestQuery(request, medicationListQuerySchema, "Invalid medication query."); + + return medicationResponse({ + ...publicMedicationPayload(q, limit, fields), + demoMode: isDemoMode() || isLocalNoAuthMode(), + publicAccess: true, + }); + } catch (error) { + return jsonError(error); + } +} diff --git a/src/components/ClinicalDashboard.tsx b/src/components/ClinicalDashboard.tsx index bb9622bf6..d8d4dbe11 100644 --- a/src/components/ClinicalDashboard.tsx +++ b/src/components/ClinicalDashboard.tsx @@ -102,6 +102,7 @@ import { SafeBoldText } from "@/components/SafeBoldText"; import { Sheet } from "@/components/ui/sheet"; import { AccountSetupDialog } from "@/components/clinical-dashboard/account-setup-dialog"; import { StagedAnswerResultSurface } from "@/components/clinical-dashboard/answer-result-surface"; +import { CrossModeLinksSection } from "@/components/clinical-dashboard/cross-mode-links"; import { RelatedDocumentsPanel } from "@/components/clinical-dashboard/document-results"; import { AnswerFollowUpSuggestions } from "@/components/clinical-dashboard/answer-follow-up-suggestions"; import { AuthPanel } from "@/components/clinical-dashboard/auth-panel"; @@ -172,6 +173,7 @@ import { DrawerGroupLabel, type DocumentDrawerMode, type DocumentDrawerStatusFilter, + type LabelReviewMutationBody, } from "@/components/clinical-dashboard/document-admin"; @@ -195,7 +197,7 @@ export const ApplicationsLauncherWorkspace = dynamic( { ssr: false }, ); const DocumentDrawer = dynamic( - () => import("@/components/clinical-dashboard/document-admin/document-drawer").then((m) => m.DocumentDrawer), + () => import("@/components/clinical-dashboard/document-admin").then((m) => m.DocumentDrawer), { ssr: false }, ); @@ -4079,6 +4081,10 @@ export function ClinicalDashboard({ const priorQueries = [...priorAnswerTurns.map((turn) => turn.query), latestAnswerQuery]; return buildAnswerFollowUpSuggestions(latestAnswerQuery, answer, priorQueries); }, [answer, latestAnswerQuery, priorAnswerTurns]); + const crossModeQueries = useMemo( + () => [...priorAnswerTurns.map((turn) => turn.query), latestAnswerQuery], + [priorAnswerTurns, latestAnswerQuery], + ); const hiddenPriorTurnCount = Math.max(0, priorAnswerTurns.length - maxVisiblePriorTurns); const visiblePriorTurns = useMemo(() => { if (showEarlierTurns || hiddenPriorTurnCount === 0) return priorAnswerTurns; @@ -4628,6 +4634,9 @@ export function ClinicalDashboard({ ) : ( <> + {searchMode === "documents" && modeSearchSubmitted && ( + + )} ) : null diff --git a/src/components/clinical-dashboard/answer-result-surface.tsx b/src/components/clinical-dashboard/answer-result-surface.tsx index b9793db7e..a46c7bbdd 100644 --- a/src/components/clinical-dashboard/answer-result-surface.tsx +++ b/src/components/clinical-dashboard/answer-result-surface.tsx @@ -6,6 +6,7 @@ import { ClipboardCheck, ExternalLink, Layers, ShieldAlert } from "lucide-react" import { type AnswerFeedbackType } from "@/lib/answer-feedback"; import { AnswerFollowUpSuggestions } from "@/components/clinical-dashboard/answer-follow-up-suggestions"; +import { CrossModeLinksSection } from "@/components/clinical-dashboard/cross-mode-links"; import { NaturalLanguageAnswer, UserQuestionBubble } from "@/components/clinical-dashboard/answer-content"; import { AnswerSupportSummaryCard, @@ -24,6 +25,7 @@ import { InlineTableCard, MobileEvidenceSheetContent } from "@/components/clinic import { Sheet } from "@/components/ui/sheet"; import { answerSurface, cn, iconTilePremium, subtleStatusPill } from "@/components/ui-primitives"; import { type AnswerRenderModel } from "@/lib/answer-render-policy"; +import { type AppModeId } from "@/lib/app-modes"; import { extractSafetyFindings } from "@/lib/clinical-safety"; import { type SourceGovernanceWarning } from "@/lib/source-governance"; import type { @@ -61,6 +63,8 @@ export function StagedAnswerResultSurface({ followUpSuggestions, onPickFollowUpSuggestion, followUpSuggestionsDisabled = false, + crossModeQueries, + onCrossModeSearch, }: { answer: RagAnswer; query: string; @@ -86,6 +90,8 @@ export function StagedAnswerResultSurface({ followUpSuggestions?: string[]; onPickFollowUpSuggestion?: (suggestion: string) => void; followUpSuggestionsDisabled?: boolean; + crossModeQueries?: Array; + onCrossModeSearch?: (mode: AppModeId, query: string) => void; }) { const noteCount = clinicalNotesCount(answer); const showClinicalNotes = @@ -226,6 +232,10 @@ export function StagedAnswerResultSurface({ /> ) : null} + {crossModeQueries?.length && onCrossModeSearch ? ( + + ) : null} + {followUpSuggestions?.length && onPickFollowUpSuggestion ? ( ; + enabled?: boolean; + // Defaults to navigating to the target mode with the search pre-run. + onModeSearch?: (mode: AppModeId, query: string) => void; +}) { + const router = useRouter(); + const services = useRegistryRecords("service", { enabled }); + const forms = useRegistryRecords("form", { enabled }); + // fields=index keeps this to the ~30 KB identity slice of the catalog. + const medications = useMedicationCatalog(undefined, { enabled, fields: "index" }); + const [differentials, setDifferentials] = useState(null); + useEffect(() => { + // Dynamic import keeps the 1.2 MB differentials snapshot out of the + // dashboard bundle; the catalog is loaded once per session. + if (!enabled || differentials) return; + let cancelled = false; + import("@/lib/cross-mode-differentials").then((module) => { + if (!cancelled) setDifferentials(module.crossModeDifferentialCatalog()); + }); + return () => { + cancelled = true; + }; + }, [enabled, differentials]); + + // Memo on the thread's contents, not the (per-render) array identity. + const queriesKey = queries.filter((value): value is string => Boolean(value?.trim())).join("\u0000"); + const links = useMemo(() => { + if (!enabled || !queriesKey) return []; + return buildCrossModeLinksForThread(queriesKey.split("\u0000"), { + medications: medications.data?.records ?? [], + services: services.records, + forms: forms.records, + differentials: differentials ?? undefined, + }); + }, [enabled, queriesKey, medications.data, services.records, forms.records, differentials]); + + if (links.length === 0) return null; + + const telemetryQuery = queriesKey.split("\u0000").at(-1) ?? ""; + const handleModeSearch = + onModeSearch ?? + ((mode: AppModeId, query: string) => { + router.push(appModeHomeHref(mode, { query, focus: true, run: true })); + }); + + return ; +} + +export function CrossModeLinksStrip({ + links, + onModeSearch, + query = "", +}: { + links: CrossModeLink[]; + onModeSearch: (mode: AppModeId, query: string) => void; + // The search text that produced the links; used only for click telemetry. + query?: string; +}) { + if (links.length === 0) return null; + + return ( +
+

+ Also in your library + {links.length > 1 ? ( + + {" "} + · {links.length} matches + + ) : null} +

+
1 && "sm:grid-cols-2")}> + {links.map((link) => { + const Icon = appModeIcons[link.modeId]; + return ( +
+
+ + + +
+
+ logCrossModeLinkOpen(query, link)} + className="inline-flex min-h-9 min-w-0 flex-1 items-center text-sm font-semibold leading-5 text-[color:var(--text-heading)] transition hover:text-[color:var(--clinical-accent)] focus-visible:outline focus-visible:outline-2 focus-visible:outline-offset-2 focus-visible:outline-[color:var(--focus)]" + > + {link.title} + + {link.modeLabel} +
+ {link.subtitle ? ( +

{link.subtitle}

+ ) : null} + {link.badges.length > 0 ? ( +
+ {link.badges.map((badge) => ( + + {badge.label} + + ))} +
+ ) : null} + +
+
+
+ ); + })} +
+
+ ); +} diff --git a/src/components/clinical-dashboard/favourites-hub.tsx b/src/components/clinical-dashboard/favourites-hub.tsx index 896d849d6..a63e156ba 100644 --- a/src/components/clinical-dashboard/favourites-hub.tsx +++ b/src/components/clinical-dashboard/favourites-hub.tsx @@ -16,6 +16,7 @@ import { import { useMemo, useRef, useState, type KeyboardEvent as ReactKeyboardEvent } from "react"; import { useDismissableLayer } from "@/components/use-dismissable-layer"; import { ModeHomeHero, ModeHomeVerificationFooter } from "@/components/mode-home-template"; +import { useSavedRegistryFavourites } from "@/components/clinical-dashboard/use-saved-registry-favourites"; import { cn, floatingControl, iconTilePremium, panelSubtle, primaryControl } from "@/components/ui-primitives"; import { favouriteItems, diff --git a/src/components/clinical-dashboard/source-actions.tsx b/src/components/clinical-dashboard/source-actions.tsx index b3654edae..ef374e88d 100644 --- a/src/components/clinical-dashboard/source-actions.tsx +++ b/src/components/clinical-dashboard/source-actions.tsx @@ -3,6 +3,7 @@ import Link from "next/link"; import { ExternalLink, FileText, Filter, Search } from "lucide-react"; import { cn, floatingControl, metadataPill, primaryControl } from "@/components/ui-primitives"; +import type { CrossModeLink } from "@/lib/cross-mode-links"; import type { SearchResult } from "@/lib/types"; export function SourceActionRow({ @@ -79,6 +80,19 @@ export function logSourceOpen(query: string, source: SearchResult) { }).catch(() => undefined); } +export function logCrossModeLinkOpen(query: string, link: Pick) { + if (!query.trim()) return; + void fetch("/api/search/interaction", { + method: "POST", + headers: { "Content-Type": "application/json" }, + body: JSON.stringify({ + query, + crossMode: { mode: link.modeId, slug: link.slug, title: link.title }, + }), + keepalive: true, + }).catch(() => undefined); +} + export function SourcePassageLinks({ heading, sources, diff --git a/src/components/clinical-dashboard/use-medication-catalog.ts b/src/components/clinical-dashboard/use-medication-catalog.ts new file mode 100644 index 000000000..074812a5c --- /dev/null +++ b/src/components/clinical-dashboard/use-medication-catalog.ts @@ -0,0 +1,145 @@ +"use client"; + +import { useEffect, useState } from "react"; + +import type { MedicationRecord, MedicationSearchResult } from "@/lib/medications"; +import { useAuthSession } from "@/lib/supabase/client"; + +type MedicationCatalogMatch = { + medication: MedicationRecord; + result: MedicationSearchResult; + score: number; + reasons: string[]; +}; + +type MedicationCatalogResponse = { + records: MedicationRecord[]; + matches?: MedicationCatalogMatch[]; + total: number; + demoMode?: boolean; +}; + +type MedicationDetailResponse = { + record: MedicationRecord; + governance?: { + sourceStatus: string; + validationStatus: string; + }; + demoMode?: boolean; +}; + +type AsyncState = { + data: T | null; + loading: boolean; + error: string | null; +}; + +async function fetchJson(url: string, headers?: HeadersInit): Promise { + const response = await fetch(url, { cache: "no-store", headers }); + if (!response.ok) { + throw new Error(`Request failed (${response.status})`); + } + return (await response.json()) as T; +} + +export function useMedicationCatalog( + query?: string, + options: { enabled?: boolean; fields?: "index" } = {}, +): AsyncState { + const enabled = options.enabled ?? true; + const fields = options.fields; + const trimmed = query?.trim() ?? ""; + // Auth-aware like use-registry-records: without the header an authenticated owner was + // silently served the public fixture catalogue instead of their seeded records. + const { authorizationHeader } = useAuthSession(); + const [prevQuery, setPrevQuery] = useState(trimmed); + const [prevEnabled, setPrevEnabled] = useState(enabled); + const [state, setState] = useState>({ + data: null, + loading: enabled, + error: null, + }); + + if (trimmed !== prevQuery || enabled !== prevEnabled) { + setPrevQuery(trimmed); + setPrevEnabled(enabled); + setState({ + data: null, + loading: enabled, + error: null, + }); + } + + useEffect(() => { + if (!enabled) return; + let cancelled = false; + const params = new URLSearchParams(); + if (trimmed) params.set("q", trimmed); + if (fields) params.set("fields", fields); + const suffix = params.toString(); + const url = suffix ? `/api/medications?${suffix}` : "/api/medications"; + fetchJson(url, authorizationHeader) + .then((data) => { + if (!cancelled) setState({ data, loading: false, error: null }); + }) + .catch((error) => { + if (!cancelled) { + setState({ + data: null, + loading: false, + error: error instanceof Error ? error.message : "Could not load medications.", + }); + } + }); + return () => { + cancelled = true; + }; + }, [trimmed, enabled, fields, authorizationHeader]); + + return state; +} + +export function useMedicationDetail(slug?: string): AsyncState { + const normalized = slug?.trim().toLowerCase() ?? ""; + const { authorizationHeader } = useAuthSession(); + const [prevSlug, setPrevSlug] = useState(normalized); + const [state, setState] = useState>(() => ({ + data: null, + loading: !!normalized, + error: null, + })); + + if (normalized !== prevSlug) { + setPrevSlug(normalized); + setState({ + data: null, + loading: !!normalized, + error: null, + }); + } + + useEffect(() => { + if (!normalized) { + return; + } + let cancelled = false; + fetchJson(`/api/medications/${encodeURIComponent(normalized)}`, authorizationHeader) + .then((data) => { + if (!cancelled) setState({ data, loading: false, error: null }); + }) + .catch((error) => { + if (!cancelled) { + setState({ + data: null, + loading: false, + error: error instanceof Error ? error.message : "Could not load medication.", + }); + } + }); + return () => { + cancelled = true; + }; + }, [normalized, authorizationHeader]); + + return state; +} diff --git a/src/lib/catalog-search.ts b/src/lib/catalog-search.ts new file mode 100644 index 000000000..b06a1daa1 --- /dev/null +++ b/src/lib/catalog-search.ts @@ -0,0 +1,173 @@ +// Shared search primitives for the registry catalogs (medications, services, forms, +// differentials, tools). Before this module each domain re-implemented its own text +// normalizer (with divergent regexes, so the same query tokenized differently per domain) +// and its own weighted includes() ranker. The domain rankers are thin wrappers over +// rankCatalogRecords with their historical field weights; the wrapper owns its reason +// labels and match shape so existing API/UI contracts are unchanged. + +import { matchesTermAtWordBoundary } from "@/lib/keyword-query"; + +// Canonical normalizer (the medications implementation — the superset of the retired +// services/forms variants: NFKD + diacritic strip, and `+ . / -` survive so dose strings +// ("5+5", "0.5mg", "IM/PO") and hyphenated clinical terms stay searchable). +export function normalizeSearchText(value: string) { + return value + .toLowerCase() + .normalize("NFKD") + .replace(/[\u0300-\u036f]/g, "") + .replace(/[^a-z0-9+./\s-]/g, " ") + .replace(/\s+/g, " ") + .trim(); +} + +export function compactSearchText(value: string) { + return value.replace(/\s+/g, ""); +} + +export type CatalogField = { + // Wrapper-facing key used to build human-readable reasons (e.g. "title", "contact"). + id: string; + weight: number; + text: (record: T) => string; +}; + +export type CatalogMatchSignals = { + // Matched term count per field id (only fields with at least one match are present). + fields: Record; + // Matched term count against the full-text haystack. + content: number; + // Matched term count for terms introduced by expandTokens (e.g. symptom + // aliases) that were not part of the raw query. + expanded: number; + compact: boolean; + phrase: boolean; + prefix: boolean; + exact: boolean; + broad: boolean; +}; + +export type CatalogRankedMatch = { + record: T; + score: number; + signals: CatalogMatchSignals; +}; + +export type RankCatalogOptions = { + fields: Array>; + // The widest haystack for the record; also the compact-match haystack. + fullText: (record: T) => string; + contentWeight?: number; + // Compact-query bonus (query with spaces removed found in the compacted haystack). + // 0 disables. compactExtraText widens the compact haystack (e.g. compacted title). + compactBonus?: number; + compactMinLength?: number; + compactExtraText?: (record: T) => string; + // Whole normalized query found in the full text. + phraseBonus?: number; + // Values compared for exact equality with the normalized query (title/slug). + exactValues?: (record: T) => string[]; + exactBonus?: number; + // Values checked for a starts-with match on the normalized query (partial + // typing of a name). 0 disables. + prefixValues?: (record: T) => string[]; + prefixBonus?: number; + prefixMinLength?: number; + // Catalogue-wide "broad intent" terms ("forms", "services") granting a flat bonus. + broadTerms?: string[]; + broadBonus?: number; + // Token expansion hook (differential alias table). Receives the deduped query terms. + expandTokens?: (terms: string[]) => string[]; + limit?: number; + // Defaults to input order (stable) when omitted. + tieBreak?: (left: T, right: T) => number; +}; + +export function rankCatalogRecords( + records: T[], + query: string, + options: RankCatalogOptions, +): Array> { + const normalizedQuery = normalizeSearchText(query); + if (!normalizedQuery) return []; + + const contentWeight = options.contentWeight ?? 2; + const compactBonus = options.compactBonus ?? 0; + const compactMinLength = options.compactMinLength ?? 4; + const phraseBonus = options.phraseBonus ?? 4; + const exactBonus = options.exactBonus ?? 10; + const prefixBonus = options.prefixBonus ?? 0; + const prefixMinLength = options.prefixMinLength ?? 3; + const broadBonus = options.broadBonus ?? 1; + + const compactQuery = compactSearchText(normalizedQuery); + const baseTerms = Array.from(new Set(normalizedQuery.split(/\s+/).filter((term) => term.length > 1))); + const terms = options.expandTokens + ? Array.from(new Set(options.expandTokens(baseTerms).filter((term) => term.length > 1))) + : baseTerms; + const baseTermSet = new Set(baseTerms); + const expandedTerms = terms.filter((term) => !baseTermSet.has(term)); + const broad = Boolean(options.broadTerms?.length && terms.some((term) => options.broadTerms!.includes(term))); + + const ranked = records + .map((record, index) => { + const text = options.fullText(record); + const fields: Record = {}; + let score = 0; + + for (const field of options.fields) { + const haystack = field.text(record); + if (!haystack) continue; + // Fields are the high-weight name/title/tag signals, so a term must + // align with a word boundary — substring hits ("renal" inside + // "adrenaline") stay confined to the low-weight content haystack. + const matched = terms.filter((term) => matchesTermAtWordBoundary(haystack, term)).length; + if (!matched) continue; + fields[field.id] = matched; + score += matched * field.weight; + } + + const content = terms.filter((term) => text.includes(term)).length; + score += content * contentWeight; + + const expanded = expandedTerms.filter((term) => text.includes(term)).length; + + const compact = + compactBonus > 0 && + compactQuery.length >= compactMinLength && + (compactSearchText(text).includes(compactQuery) || + (options.compactExtraText + ? compactSearchText(options.compactExtraText(record)).includes(compactQuery) + : false)); + if (compact) score += compactBonus; + + const phrase = phraseBonus > 0 && text.includes(normalizedQuery); + if (phrase) score += phraseBonus; + + const exact = Boolean(options.exactValues?.(record).some((value) => value === normalizedQuery)); + if (exact) score += exactBonus; + + const prefix = + prefixBonus > 0 && + normalizedQuery.length >= prefixMinLength && + Boolean(options.prefixValues?.(record).some((value) => value.startsWith(normalizedQuery))); + if (prefix) score += prefixBonus; + + if (broad) score += broadBonus; + + return { + record, + index, + score, + signals: { fields, content, expanded, compact, phrase, prefix, exact, broad } satisfies CatalogMatchSignals, + }; + }) + .filter((match) => match.score > 0) + .sort( + (left, right) => + right.score - left.score || + (options.tieBreak ? options.tieBreak(left.record, right.record) : left.index - right.index), + ) + .map(({ record, score, signals }) => ({ record, score, signals })); + + return options.limit !== undefined ? ranked.slice(0, options.limit) : ranked; +} diff --git a/src/lib/cross-mode-differentials.ts b/src/lib/cross-mode-differentials.ts new file mode 100644 index 000000000..65c57eb59 --- /dev/null +++ b/src/lib/cross-mode-differentials.ts @@ -0,0 +1,40 @@ +import type { CrossModeDifferentialCatalog } from "@/lib/cross-mode-links"; +import { differentialRecords } from "@/lib/differentials"; + +const supplementalDiagnoses = [ + { + slug: "acute-psychosis", + title: "Acute Psychosis", + clinicalHinge: "Acute psychotic symptoms require safety review and rapid medical exclusion.", + }, + { + slug: "aggression-violence-homicidal-ideation", + title: "Aggression / Violence / Homicidal Ideation", + clinicalHinge: "Acute aggression or homicidal intent threatens immediate safety and may signal delirium, intoxication or mania.", + }, +] as const; + +// Load this module with a dynamic import only: it statically pulls the +// differentials catalog, which stays code-split out of the dashboard bundle. +export function crossModeDifferentialCatalog(): CrossModeDifferentialCatalog { + const diagnoses = [ + ...differentialRecords.map((record) => ({ + slug: record.slug, + title: record.title, + clinicalHinge: record.clinicalHinge, + })), + ...supplementalDiagnoses.map((record) => ({ ...record })), + ]; + + return { + diagnoses, + presentations: [], + aliases: { + psychotic: ["psychosis", "schizophrenia"], + psychosis: ["psychotic", "schizophrenia"], + aggression: ["violence", "homicidal"], + violence: ["aggression", "homicidal"], + homicidal: ["aggression", "violence"], + }, + }; +} diff --git a/src/lib/cross-mode-links.ts b/src/lib/cross-mode-links.ts new file mode 100644 index 000000000..7da1b82ce --- /dev/null +++ b/src/lib/cross-mode-links.ts @@ -0,0 +1,273 @@ +import { appModeDefinition, appModeHomeHref, type AppModeId } from "@/lib/app-modes"; +import { rankFormRecords, type FormRecord } from "@/lib/forms"; +import { + medicationIdentityBadges, + medicationIndication, + rankMedicationRecords, + type MedicationRecord, +} from "@/lib/medications"; +import { extractKeywordTerms } from "@/lib/keyword-query"; +import { rankServiceRecords, type ServiceRecord } from "@/lib/services"; + +export type CrossModeLinkModeId = Extract; + +export type CrossModeLinkBadge = { + label: string; + tone?: "clinical" | "success" | "danger" | "warning" | "neutral" | "info"; +}; + +export type CrossModeLink = { + modeId: CrossModeLinkModeId; + modeLabel: string; + slug: string; + title: string; + subtitle: string; + badges: CrossModeLinkBadge[]; + detailHref: string; + modeSearchHref: string; + modeSearchQuery: string; + score: number; + matchReason: string; +}; + +export type CrossModeDifferentialCatalog = { + diagnoses: Array<{ slug: string; title: string; clinicalHinge: string }>; + presentations: Array<{ id: string; title: string; subtitle: string }>; + aliases: Record; +}; + +// The differential catalog is injected (not imported) so this module never +// statically pulls the 1.2 MB differentials snapshot — or the 3.4 MB +// medications snapshot — into the dashboard bundle. +export type CrossModeCatalogs = { + medications?: MedicationRecord[]; + services?: ServiceRecord[]; + forms?: FormRecord[]; + differentials?: CrossModeDifferentialCatalog; +}; + +export type CrossModeLinkOptions = { + maxPerMode?: number; + maxTotal?: number; +}; + +// The gate for every mode is "the query names the entity" (a name/title-level +// match), not raw score: question filler like "dose" or "patient" survives +// keyword extraction and content-matches nearly every record for ~2 points per +// term, so content-only scores can never be trusted on their own. +const MEDICATION_MIN_SCORE = 10; // one name-term hit: 8 (name) + 2 (content echo) +const SERVICE_MIN_SCORE = 8; // one title-term hit: 6 (title) + 2 (content echo) +const DIFFERENTIAL_TITLE_TERM_SCORE = 8; + +const RANKER_CANDIDATE_LIMIT = 5; + +const modePriority: Record = { + prescribing: 0, + services: 1, + forms: 2, + differentials: 3, +}; + +function crossModeLinkBase(modeId: CrossModeLinkModeId, title: string) { + return { + modeId, + modeLabel: appModeDefinition(modeId).label, + title, + modeSearchHref: appModeHomeHref(modeId, { query: title, focus: true, run: true }), + modeSearchQuery: title, + }; +} + +function serviceChipBadges(record: ServiceRecord): CrossModeLinkBadge[] { + const badges: CrossModeLinkBadge[] = []; + for (const chip of record.statusChips ?? []) { + const label = chip.label?.trim(); + if (!label) continue; + badges.push({ label, tone: chip.tone ?? undefined }); + if (badges.length === 2) break; + } + return badges; +} + +// The rankers match name/title terms by substring, which lets query words hide +// inside entity names ("renal" inside "adrenaline"). A term only counts as +// naming an entity when it aligns with a word boundary; prefixes are accepted +// for longer terms so plural/possessive drift still matches. +function hasWordBoundaryMatch(value: string, terms: string[]) { + const words = value + .toLowerCase() + .replace(/[^a-z0-9]+/g, " ") + .trim() + .split(" ") + .filter(Boolean); + return terms.some((term) => words.some((word) => word === term || (term.length >= 5 && word.startsWith(term)))); +} + +function medicationLinks(query: string, terms: string[], records: MedicationRecord[]): CrossModeLink[] { + return rankMedicationRecords(records, query, RANKER_CANDIDATE_LIMIT) + .filter( + (match) => + match.score >= MEDICATION_MIN_SCORE && + (match.reasons.includes("name") || match.reasons.includes("exact name")) && + hasWordBoundaryMatch(`${match.medication.name} ${match.medication.slug}`, terms), + ) + .map((match) => ({ + ...crossModeLinkBase("prescribing", match.medication.name), + slug: match.medication.slug, + subtitle: medicationIndication(match.medication), + badges: medicationIdentityBadges(match.medication).slice(0, 2), + detailHref: `/medications/${match.medication.slug}`, + score: match.score, + matchReason: match.reasons.join(" · "), + })); +} + +function registryLinks( + modeId: Extract, + query: string, + terms: string[], + records: ServiceRecord[], +): CrossModeLink[] { + const ranker = modeId === "services" ? rankServiceRecords : rankFormRecords; + return ranker(records, query, RANKER_CANDIDATE_LIMIT) + .filter( + (match) => + match.score >= SERVICE_MIN_SCORE && + match.reasons.includes("title") && + hasWordBoundaryMatch(`${match.service.title} ${match.service.slug}`, terms), + ) + .map((match) => ({ + ...crossModeLinkBase(modeId, match.service.title), + slug: match.service.slug, + subtitle: match.service.subtitle?.trim() || match.service.route?.trim() || "", + badges: serviceChipBadges(match.service), + detailHref: `/${modeId}/${match.service.slug}`, + score: match.score, + matchReason: match.reasons.join(" · "), + })); +} + +function differentialTitleScore(title: string, terms: string[], aliasDerived: Set) { + // Word-boundary matching keeps substring junk out; a matching term must + // also be at least 4 chars unless it came from a curated alias. + const matches = terms.filter( + (term) => (term.length >= 4 || aliasDerived.has(term)) && hasWordBoundaryMatch(title, [term]), + ); + return matches.length * DIFFERENTIAL_TITLE_TERM_SCORE; +} + +function differentialLinks(terms: string[], catalog: CrossModeDifferentialCatalog): CrossModeLink[] { + if (terms.length === 0) return []; + + const aliasDerived = new Set(); + const expanded = new Set(terms); + for (const term of terms) { + for (const alias of catalog.aliases[term] ?? []) { + const normalizedAlias = alias.toLowerCase(); + if (!expanded.has(normalizedAlias)) aliasDerived.add(normalizedAlias); + expanded.add(normalizedAlias); + } + } + const expandedTerms = [...expanded]; + + const candidates: CrossModeLink[] = []; + for (const record of catalog.diagnoses) { + const score = differentialTitleScore(record.title, expandedTerms, aliasDerived); + if (score < DIFFERENTIAL_TITLE_TERM_SCORE) continue; + candidates.push({ + ...crossModeLinkBase("differentials", record.title), + slug: record.slug, + subtitle: record.clinicalHinge, + badges: [], + detailHref: `/differentials/diagnoses/${record.slug}`, + score, + matchReason: "title", + }); + } + for (const presentation of catalog.presentations) { + const score = differentialTitleScore(presentation.title, expandedTerms, aliasDerived); + if (score < DIFFERENTIAL_TITLE_TERM_SCORE) continue; + candidates.push({ + ...crossModeLinkBase("differentials", presentation.title), + slug: presentation.id, + subtitle: presentation.subtitle, + badges: [], + detailHref: `/differentials/presentations/${presentation.id}`, + score, + matchReason: "title", + }); + } + + return candidates + .sort((left, right) => right.score - left.score || left.title.localeCompare(right.title)) + .slice(0, 1); +} + +// Follow-ups often drop the entity name ("what about renal impairment?"), so +// an answer thread resolves links from its newest turn that names an entity — +// walking all the way back, not just one turn, keeps the entity's card alive +// through consecutive entity-free follow-ups. Queries are ordered oldest first. +export function buildCrossModeLinksForThread( + queries: Array, + catalogs: CrossModeCatalogs, + options: CrossModeLinkOptions = {}, +): CrossModeLink[] { + for (let index = queries.length - 1; index >= 0; index -= 1) { + const query = queries[index]?.trim(); + if (!query) continue; + const links = buildCrossModeLinks(query, catalogs, options); + if (links.length > 0) return links; + } + return []; +} + +export function buildCrossModeLinks( + query: string, + catalogs: CrossModeCatalogs, + options: CrossModeLinkOptions = {}, +): CrossModeLink[] { + const maxPerMode = options.maxPerMode ?? 2; + const maxTotal = options.maxTotal ?? 4; + + const terms = extractKeywordTerms(query); + if (terms.length === 0) return []; + const keywordQuery = terms.join(" "); + + const candidates = [ + ...medicationLinks(keywordQuery, terms, catalogs.medications ?? []), + ...registryLinks("services", keywordQuery, terms, catalogs.services ?? []), + ...registryLinks("forms", keywordQuery, terms, catalogs.forms ?? []), + ...(catalogs.differentials ? differentialLinks(terms, catalogs.differentials) : []), + ]; + + candidates.sort( + (left, right) => + right.score - left.score || + modePriority[left.modeId] - modePriority[right.modeId] || + left.title.localeCompare(right.title), + ); + + const seenKeys = new Set(); + // A slug shared between the services and forms registries is the same + // record surfaced twice; keep only the higher-scoring occurrence. + const seenRegistrySlugs = new Set(); + const perModeCounts: Partial> = {}; + const links: CrossModeLink[] = []; + + for (const candidate of candidates) { + if (links.length >= maxTotal) break; + const key = `${candidate.modeId}:${candidate.slug}`; + if (seenKeys.has(key)) continue; + if (candidate.modeId === "services" || candidate.modeId === "forms") { + if (seenRegistrySlugs.has(candidate.slug)) continue; + seenRegistrySlugs.add(candidate.slug); + } + const modeCount = perModeCounts[candidate.modeId] ?? 0; + if (modeCount >= maxPerMode) continue; + seenKeys.add(key); + perModeCounts[candidate.modeId] = modeCount + 1; + links.push(candidate); + } + + return links; +} diff --git a/src/lib/keyword-query.ts b/src/lib/keyword-query.ts new file mode 100644 index 000000000..ac2236651 --- /dev/null +++ b/src/lib/keyword-query.ts @@ -0,0 +1,104 @@ +export const keywordStopWords = new Set([ + "a", + "about", + "all", + "an", + "and", + "are", + "as", + "at", + "be", + "before", + "both", + "by", + "can", + "could", + "did", + "do", + "does", + "for", + "from", + "get", + "had", + "has", + "have", + "her", + "his", + "how", + "if", + "in", + "is", + "it", + "its", + "into", + "me", + "may", + "more", + "my", + "no", + "not", + "of", + "on", + "or", + "our", + "out", + "should", + "so", + "such", + "that", + "the", + "their", + "them", + "there", + "these", + "they", + "this", + "those", + "to", + "when", + "where", + "which", + "who", + "why", + "with", + "would", + "you", +]); + +export function extractKeywordTerms(query: string, options: { maxTerms?: number } = {}): string[] { + const maxTerms = options.maxTerms ?? 12; + const normalized = query + .normalize("NFKD") + .toLowerCase() + .replace(/[^\w\s]+/g, " ") + .replace(/_/g, " ") + .trim(); + const tokens = normalized.split(/\s+/).filter((token) => token.length >= 3 && !keywordStopWords.has(token)); + const terms: string[] = []; + const seen = new Set(); + + for (const token of tokens) { + if (seen.has(token)) continue; + seen.add(token); + terms.push(token); + } + + return terms.slice(0, maxTerms); +} + +export function keywordQueryFromNaturalLanguage(query: string) { + return extractKeywordTerms(query, { maxTerms: 7 }).join(" "); +} + +// A query term only counts against a name/title when it aligns with a word +// boundary — exact word, or word prefix to keep search-as-you-type working — +// so terms cannot hide inside words ("renal" inside "adrenaline"). Words are +// split on every non-alphanumeric so tokens like "im/po" or "co-codamol" +// match on their parts. +export function matchesTermAtWordBoundary(text: string, term: string) { + if (!term) return false; + return text + .toLowerCase() + .split(/[^a-z0-9]+/) + .some((word) => word === term || word.startsWith(term)); +} diff --git a/src/lib/medication-badges.ts b/src/lib/medication-badges.ts new file mode 100644 index 000000000..668591ebe --- /dev/null +++ b/src/lib/medication-badges.ts @@ -0,0 +1,356 @@ +import { SEMANTIC_TONE_PRIORITY, type SemanticIconKey, type SemanticTone } from "@/lib/semantic-tone"; +import type { + MedicationPatientMetadata, + MedicationRecord, + MedicationSectionRow, + MedicationStat, +} from "@/lib/medications"; + +export type MedicationGovernance = { + sourceStatus?: string; + validationStatus?: string; +}; + +export type MedicationBadge = { + id: string; + label: string; + tone: SemanticTone; + // Optional semantic icon key resolved by ClinicalBadge (e.g. controlled-drug + // lock). Danger/warning badges already get a default icon from their tone, so + // this is only set where a specific icon is meaningful. + iconKey?: SemanticIconKey; +}; + +const TAG_TONES: Record = { + PBS: "success", + TGA: "info", + OFF: "warning", +}; + +const FACTOR_LABELS: Record = { + renal: "Renal", + hepatic: "Hepatic", + pregnancy: "Pregnancy", + lactation: "Breastfeeding", + elderly: "Elderly", + paediatric: "Paediatric", +}; + +function sectionByType(record: MedicationRecord, type: string) { + return record.sections.find((section) => section.type === type); +} + +function firstRowValue(record: MedicationRecord, type: string, keyIncludes?: string) { + const section = sectionByType(record, type); + if (!section) return ""; + const row = keyIncludes + ? section.rows.find((item) => item.key.toLowerCase().includes(keyIncludes.toLowerCase())) + : section.rows[0]; + return row?.val?.trim() ?? ""; +} + +function firstRow(record: MedicationRecord, type: string, keyIncludes?: string) { + const section = sectionByType(record, type); + if (!section) return undefined; + return keyIncludes + ? section.rows.find((item) => item.key.toLowerCase().includes(keyIncludes.toLowerCase())) + : section.rows[0]; +} + +function quickValue(record: MedicationRecord, labelIncludes: string) { + const row = record.quick.find((item) => item.label.toLowerCase().includes(labelIncludes.toLowerCase())); + return row?.value?.trim() ?? ""; +} + +function pushBadge(badges: MedicationBadge[], badge: MedicationBadge) { + if (!badges.some((existing) => existing.id === badge.id)) { + badges.push(badge); + } +} + +export function dedupeBadges(badges: MedicationBadge[]): MedicationBadge[] { + const seen = new Set(); + return badges.filter((badge) => { + if (seen.has(badge.id)) return false; + seen.add(badge.id); + return true; + }); +} + +export function sortBadgesByPriority(badges: MedicationBadge[]): MedicationBadge[] { + return [...badges].sort((a, b) => SEMANTIC_TONE_PRIORITY[b.tone] - SEMANTIC_TONE_PRIORITY[a.tone]); +} + +function formulationShortLabel(value: string): string | null { + const cleaned = value + .replace(/\*\*/g, "") + .replace(/\s*\([^)]*\)\s*$/, "") + .trim(); + if (!cleaned) return null; + + const mgMatch = cleaned.match(/(\d+)\s*mg/i); + if (mgMatch) { + const mg = mgMatch[1]; + const isEc = /enteric/i.test(cleaned); + const isTab = /tablet/i.test(cleaned); + if (isEc && isTab) return `${mg} mg EC tablet`; + if (isTab) return `${mg} mg tablet`; + if (isEc) return `${mg} mg EC`; + return `${mg} mg`; + } + + const firstSentence = cleaned.split(".")[0]?.trim() ?? ""; + if (!firstSentence) return null; + return firstSentence.length > 28 ? `${firstSentence.slice(0, 28).trim()}…` : firstSentence; +} + +function parsePbsBadges(pbsText: string, badges: MedicationBadge[]) { + const upper = pbsText.toUpperCase(); + if (upper.includes("STREAMLINED PBS")) { + pushBadge(badges, { id: "identity-pbs-streamlined", label: "PBS streamlined", tone: "success" }); + } else if (/AUTHORITY REQUIRED/i.test(pbsText)) { + pushBadge(badges, { id: "identity-pbs-authority", label: "Authority required", tone: "warning" }); + } + + const itemMatch = pbsText.match(/\bitem\s+(\d{4}[A-Z])\b/i) ?? pbsText.match(/\b(\d{4}[A-Z])\b/); + if (itemMatch?.[1]) { + pushBadge(badges, { id: `identity-pbs-item-${itemMatch[1]}`, label: itemMatch[1], tone: "neutral" }); + } +} + +function isReviewed(record: MedicationRecord, governance?: MedicationGovernance) { + if (governance?.validationStatus === "locally_reviewed" || governance?.validationStatus === "approved") { + return true; + } + const sourceText = firstRowValue(record, "src", "source review").toLowerCase(); + return sourceText.includes("checked"); +} + +function patientBadges(patient: MedicationPatientMetadata, prefix: string, badges: MedicationBadge[]) { + const match = patient.match ?? {}; + const scr = match.scr as { gt?: number } | undefined; + if (typeof scr?.gt === "number") { + pushBadge(badges, { + id: `${prefix}-scr-gt-${scr.gt}`, + label: `Cr >${scr.gt} avoid`, + tone: "danger", + }); + } + + const age = match.age as { lt?: number; gt?: number } | undefined; + if (typeof age?.lt === "number") { + pushBadge(badges, { + id: `${prefix}-age-lt-${age.lt}`, + label: `Avoid <${age.lt} years`, + tone: "warning", + }); + } + if (typeof age?.gt === "number") { + pushBadge(badges, { + id: `${prefix}-age-gt-${age.gt}`, + label: `Avoid >${age.gt} years`, + tone: "warning", + }); + } + + const action = patient.action ?? ""; + const severity = patient.severity === "danger" ? "danger" : action === "contraindication" ? "danger" : "warning"; + const factorTone: SemanticTone = + action === "monitor" || action === "dose-adjust" ? "clinical" : severity === "danger" ? "danger" : "warning"; + + for (const factor of patient.factors ?? []) { + const label = FACTOR_LABELS[factor] ?? factor.charAt(0).toUpperCase() + factor.slice(1); + pushBadge(badges, { + id: `${prefix}-factor-${factor}`, + label, + tone: action === "contraindication" ? "danger" : factorTone, + }); + } +} + +function textHeuristicBadges( + row: MedicationSectionRow, + sectionType: string, + prefix: string, + badges: MedicationBadge[], +) { + const val = row.val.replace(/\*\*/g, ""); + const keyLower = row.key.toLowerCase(); + const combined = `${row.key} ${val}`.toLowerCase(); + + if (/^critical\b/i.test(val) || /^contraindicated\b/i.test(val)) { + pushBadge(badges, { id: `${prefix}-contraindicated`, label: "Contraindicated", tone: "danger" }); + } + + if (sectionType === "risk") { + const severityMatch = val.match(/^(HIGH|MODERATE|LOW)\b/i); + if (severityMatch?.[1]) { + const level = severityMatch[1].toUpperCase(); + pushBadge(badges, { + id: `${prefix}-severity-${level}`, + label: level.charAt(0) + level.slice(1).toLowerCase(), + tone: level === "HIGH" ? "warning" : "neutral", + }); + } + } + + if (combined.includes("<60 kg") || combined.includes("< 60 kg")) { + pushBadge(badges, { id: `${prefix}-reduce-60kg`, label: "Reduce <60 kg", tone: "warning" }); + } + if (combined.includes("child-pugh c")) { + pushBadge(badges, { id: `${prefix}-child-pugh-c`, label: "Child-Pugh C", tone: "danger" }); + } + if (combined.includes("do not crush")) { + pushBadge(badges, { id: `${prefix}-do-not-crush`, label: "Do not crush", tone: "warning" }); + } + if (combined.includes("take with food") || combined.includes("with meals")) { + pushBadge(badges, { id: `${prefix}-with-food`, label: "Take with food", tone: "clinical" }); + } + + if (sectionType === "dose" && keyLower.includes("renal")) { + pushBadge(badges, { id: `${prefix}-renal-adjust`, label: "Renal adjustment", tone: "warning" }); + } +} + +export function medicationIdentityBadges( + record: MedicationRecord, + governance?: MedicationGovernance, +): MedicationBadge[] { + const badges: MedicationBadge[] = []; + + if (record.tag) { + pushBadge(badges, { id: "identity-tag", label: record.tag, tone: "neutral" }); + } + if (record.schedule) { + // S8 (controlled drug) is a regulatory classification, not a clinical stop + // state. Give it a dedicated "controlled" treatment — warning tone + lock + // icon — so red stays reserved for true contraindications/do-not-use. + const isControlled = record.schedule === "S8"; + pushBadge(badges, { + id: "identity-schedule", + label: record.schedule, + tone: isControlled ? "warning" : "info", + ...(isControlled ? { iconKey: "controlled" as const } : {}), + }); + } + + const brand = firstRowValue(record, "form", "brand"); + if (brand) { + pushBadge(badges, { id: "identity-brand", label: brand.replace(/\*\*/g, ""), tone: "neutral" }); + } + + const formulation = formulationShortLabel(quickValue(record, "route / formulation")); + if (formulation) { + pushBadge(badges, { id: "identity-formulation", label: formulation, tone: "neutral" }); + } + + const primaryRow = firstRow(record, "ind", "primary"); + for (const tag of primaryRow?.tags ?? []) { + pushBadge(badges, { + id: `identity-ind-tag-${tag}`, + label: tag, + tone: TAG_TONES[tag] ?? "neutral", + }); + } + + const pbsText = firstRowValue(record, "form", "prescribing & pbs"); + if (pbsText) { + parsePbsBadges(pbsText, badges); + } + + if (isReviewed(record, governance)) { + pushBadge(badges, { id: "identity-reviewed", label: "Reviewed", tone: "success" }); + } + + if (governance?.sourceStatus === "review_due") { + pushBadge(badges, { id: "identity-review-due", label: "Review due", tone: "warning" }); + } else if (governance?.sourceStatus === "outdated") { + pushBadge(badges, { id: "identity-outdated", label: "Outdated", tone: "danger" }); + } + + return sortBadgesByPriority(dedupeBadges(badges)); +} + +export function medicationRowBadges(row: MedicationSectionRow, sectionType: string): MedicationBadge[] { + const badges: MedicationBadge[] = []; + const prefix = `row-${sectionType}-${row.key}`.replace(/\s+/g, "-").toLowerCase(); + + if (row.patient) { + patientBadges(row.patient, prefix, badges); + } + + for (const tag of row.tags ?? []) { + pushBadge(badges, { + id: `${prefix}-tag-${tag}`, + label: tag, + tone: TAG_TONES[tag] ?? "info", + }); + } + + textHeuristicBadges(row, sectionType, prefix, badges); + + const limit = sectionType === "contra" || badges.some((badge) => badge.tone === "danger") ? 4 : 3; + return sortBadgesByPriority(dedupeBadges(badges)).slice(0, limit); +} + +export function medicationAccessBadges(record: MedicationRecord): MedicationBadge[] { + const badges: MedicationBadge[] = []; + const brand = firstRowValue(record, "form", "brand"); + if (brand) { + pushBadge(badges, { id: "access-brand", label: brand.replace(/\*\*/g, ""), tone: "neutral" }); + } + + const pbsText = firstRowValue(record, "form", "prescribing & pbs"); + if (pbsText) { + parsePbsBadges(pbsText, badges); + const itemMatch = pbsText.match(/\bitem\s+(\d{4}[A-Z])\b/i); + if (itemMatch?.[1]) { + pushBadge(badges, { id: `access-item-${itemMatch[1]}`, label: `Item ${itemMatch[1]}`, tone: "neutral" }); + } + } + + const routes = firstRowValue(record, "form", "oral routes"); + if (routes) { + const short = formulationShortLabel(routes); + if (short) { + pushBadge(badges, { id: "access-formulation", label: short, tone: "neutral" }); + } + } + + return sortBadgesByPriority(dedupeBadges(badges)).slice(0, 4); +} + +export function medicationStatTone(stat: MedicationStat): SemanticTone { + const cls = stat.cls?.toLowerCase() ?? ""; + const flag = stat.flag?.toLowerCase() ?? ""; + if (cls === "hi" || flag === "hi") return "danger"; + if (cls === "warn" || flag === "warn") return "warning"; + if (cls === "good") return "success"; + return "neutral"; +} + +export function medicationAccessFields(record: MedicationRecord): Array<{ label: string; value: string }> { + const fields: Array<{ label: string; value: string }> = []; + const brand = firstRowValue(record, "form", "brand"); + if (brand) fields.push({ label: "Brand", value: brand.replace(/\*\*/g, "") }); + + const pbsText = firstRowValue(record, "form", "prescribing & pbs"); + if (pbsText) { + if (/STREAMLINED PBS/i.test(pbsText)) { + fields.push({ label: "PBS status", value: "PBS streamlined" }); + } else if (/AUTHORITY REQUIRED/i.test(pbsText)) { + fields.push({ label: "PBS status", value: "Authority required" }); + } + const itemMatch = pbsText.match(/\bitem\s+(\d{4}[A-Z])\b/i); + if (itemMatch?.[1]) { + fields.push({ label: "PBS item", value: itemMatch[1] }); + } + } + + const routes = firstRowValue(record, "form", "oral routes"); + if (routes) { + fields.push({ label: "Formulation", value: routes.replace(/\*\*/g, "").split(".")[0]?.trim() ?? routes }); + } + + return fields; +} diff --git a/src/lib/medication-fixtures.ts b/src/lib/medication-fixtures.ts new file mode 100644 index 000000000..6df806434 --- /dev/null +++ b/src/lib/medication-fixtures.ts @@ -0,0 +1,5 @@ +import { loadMedicationSnapshot } from "@/lib/medication-snapshot"; + +export function defaultMedicationRecords() { + return loadMedicationSnapshot(); +} diff --git a/src/lib/medication-records.ts b/src/lib/medication-records.ts new file mode 100644 index 000000000..a7a2c17a3 --- /dev/null +++ b/src/lib/medication-records.ts @@ -0,0 +1,50 @@ +import type { MedicationRecord } from "@/lib/medications"; + +export type MedicationSourceStatus = "current" | "review_due" | "outdated" | "unknown"; +export type MedicationValidationStatus = "unverified" | "locally_reviewed" | "approved"; + +const sourceStatuses: readonly MedicationSourceStatus[] = ["current", "review_due", "outdated", "unknown"]; +const validationStatuses: readonly MedicationValidationStatus[] = ["unverified", "locally_reviewed", "approved"]; + +export function normalizeMedicationSlug(value: string) { + return value.trim().toLowerCase(); +} + +export function medicationSourceStatus(value: string | null | undefined): MedicationSourceStatus { + return sourceStatuses.find((status) => status === value) ?? "unknown"; +} + +export function medicationValidationStatus(value: string | null | undefined): MedicationValidationStatus { + return validationStatuses.find((status) => status === value) ?? "unverified"; +} + +export function deriveGovernanceFromSections(record: MedicationRecord): { + source_status: MedicationSourceStatus; + validation_status: MedicationValidationStatus; +} { + const sourceSection = record.sections.find((section) => section.type === "src"); + const sourceText = + sourceSection?.rows + .map((row) => row.val) + .join(" ") + .toLowerCase() ?? ""; + const sourceStatus: MedicationSourceStatus = sourceText.includes("checked") + ? "current" + : sourceText.includes("review") + ? "review_due" + : "unknown"; + return { + source_status: sourceStatus, + validation_status: "locally_reviewed", + }; +} + +export function rowGovernance(row: { + source_status: string | null; + validation_status: string | null; +}) { + return { + sourceStatus: medicationSourceStatus(row.source_status), + validationStatus: medicationValidationStatus(row.validation_status), + }; +} diff --git a/src/lib/medication-seed.ts b/src/lib/medication-seed.ts new file mode 100644 index 000000000..7f073fdf5 --- /dev/null +++ b/src/lib/medication-seed.ts @@ -0,0 +1,3 @@ +import { defaultMedicationRecords } from "@/lib/medication-fixtures"; + +export { defaultMedicationRecords }; diff --git a/src/lib/medication-snapshot.ts b/src/lib/medication-snapshot.ts new file mode 100644 index 000000000..42acf02b0 --- /dev/null +++ b/src/lib/medication-snapshot.ts @@ -0,0 +1,17 @@ +import medicationsSnapshot from "../../data/medications-snapshot.json"; + +import { normalizeMedicationSlug, normalizeRecord, type MedicationRecord } from "@/lib/medications"; + +let cachedSnapshot: MedicationRecord[] | null = null; + +export function loadMedicationSnapshot(): MedicationRecord[] { + if (cachedSnapshot) return cachedSnapshot; + const raw = medicationsSnapshot as MedicationRecord[]; + cachedSnapshot = raw.map(normalizeRecord).sort((left, right) => left.name.localeCompare(right.name)); + return cachedSnapshot; +} + +export function getMedicationRecord(slug: string): MedicationRecord | undefined { + const normalized = normalizeMedicationSlug(slug); + return loadMedicationSnapshot().find((record) => record.slug === normalized); +} diff --git a/src/lib/medications.ts b/src/lib/medications.ts new file mode 100644 index 000000000..56965521c --- /dev/null +++ b/src/lib/medications.ts @@ -0,0 +1,271 @@ +import { normalizeSearchText, rankCatalogRecords } from "@/lib/catalog-search"; + +export type MedicationPatientMetadata = { + factors?: string[]; + action?: string; + severity?: string; + match?: Record; + note?: string; +}; + +export type MedicationSectionRow = { + key: string; + val: string; + tags?: string[]; + patient?: MedicationPatientMetadata | null; +}; + +export type MedicationSection = { + title: string; + type: string; + rows: MedicationSectionRow[]; +}; + +export type MedicationStat = { + label: string; + value: string; + cls?: string; + flag?: string; +}; + +export type MedicationQuickRow = { + label: string; + value: string; +}; + +export type MedicationRecord = { + slug: string; + name: string; + class: string; + subclass: string; + category: string; + accent: string; + tag: string; + schedule: string; + stats: MedicationStat[]; + sections: MedicationSection[]; + quick: MedicationQuickRow[]; +}; + +export type MedicationSearchMatch = { + medication: MedicationRecord; + score: number; + reasons: string[]; +}; + +export type MedicationResultTone = "teal" | "blue" | "slate"; + +export type MedicationSearchResult = { + id: string; + name: string; + indication: string; + match: string; + dose: string; + ceiling: string; + action: string; + tone: MedicationResultTone; + href: string; +}; + +export function normalizeMedicationSlug(value: string) { + return value.trim().toLowerCase(); +} + +export { normalizeSearchText }; + +export function normalizeRecord(record: MedicationRecord): MedicationRecord { + return { + ...record, + slug: normalizeMedicationSlug(record.slug), + name: record.name.trim(), + class: record.class?.trim() ?? "", + subclass: record.subclass?.trim() ?? "", + category: record.category?.trim() ?? "", + accent: record.accent?.trim() || "#0f766e", + tag: record.tag?.trim() ?? "", + schedule: record.schedule?.trim() ?? "", + stats: Array.isArray(record.stats) ? record.stats : [], + sections: Array.isArray(record.sections) ? record.sections : [], + quick: Array.isArray(record.quick) ? record.quick : [], + }; +} + +function sectionByType(record: MedicationRecord, type: string) { + return record.sections.find((section) => section.type === type); +} + +function firstRowValue(record: MedicationRecord, type: string, keyIncludes?: string) { + const section = sectionByType(record, type); + if (!section) return ""; + const row = keyIncludes + ? section.rows.find((item) => item.key.toLowerCase().includes(keyIncludes.toLowerCase())) + : section.rows[0]; + return row?.val?.trim() ?? ""; +} + +function statValue(record: MedicationRecord, labelIncludes: string) { + const stat = record.stats.find((item) => item.label.toLowerCase().includes(labelIncludes.toLowerCase())); + return stat?.value?.trim() ?? ""; +} + +function quickValue(record: MedicationRecord, labelIncludes: string) { + const row = record.quick.find((item) => item.label.toLowerCase().includes(labelIncludes.toLowerCase())); + return row?.value?.trim() ?? ""; +} + +export function medicationSearchText(record: MedicationRecord) { + const sectionText = record.sections + .flatMap((section) => [section.title, ...section.rows.flatMap((row) => [row.key, row.val, ...(row.tags ?? [])])]) + .join(" "); + const quickText = record.quick.map((row) => `${row.label} ${row.value}`).join(" "); + const statText = record.stats.map((stat) => `${stat.label} ${stat.value}`).join(" "); + return normalizeSearchText( + [ + record.name, + record.slug, + record.class, + record.subclass, + record.category, + record.tag, + record.schedule, + sectionText, + quickText, + statText, + ].join(" "), + ); +} + +export function medicationIndication(record: MedicationRecord) { + return ( + firstRowValue(record, "ind", "primary") || + firstRowValue(record, "summary", "overview") || + record.subclass || + record.category + ); +} + +export function medicationUsualDose(record: MedicationRecord) { + const quickDose = quickValue(record, "usual dose"); + if (quickDose) return quickDose.replace(/\*\*/g, "").split(".")[0]?.trim() ?? quickDose; + const doseRow = sectionByType(record, "dose")?.rows[0]; + return doseRow?.val?.replace(/\*\*/g, "").split(".")[0]?.trim() ?? "See dosing"; +} + +export function medicationCeiling(record: MedicationRecord) { + return statValue(record, "max dose") || statValue(record, "ceiling") || "See reference"; +} + +export function medicationAction(record: MedicationRecord) { + return ( + quickValue(record, "avoid") || + firstRowValue(record, "contra", "absolute") || + firstRowValue(record, "summary", "clinical focus") || + firstRowValue(record, "mon", "laboratory") || + "Review full prescribing reference." + ) + .replace(/\*\*/g, "") + .split(".")[0] + ?.trim(); +} + +export function medicationResultTone(record: MedicationRecord, score: number): MedicationResultTone { + if (score >= 12) return "teal"; + if (score >= 6) return "blue"; + return "slate"; +} + +export function medicationToSearchResult(match: MedicationSearchMatch): MedicationSearchResult { + const { medication, score } = match; + return { + id: medication.slug, + name: medication.name, + indication: medicationIndication(medication), + match: score >= 12 ? "Exact clinical fit" : score >= 6 ? "Good clinical fit" : "Related match", + dose: medicationUsualDose(medication), + ceiling: medicationCeiling(medication), + action: medicationAction(medication) ?? "Review full prescribing reference.", + tone: medicationResultTone(medication, score), + href: `/medications/${medication.slug}`, + }; +} + +export function rankMedicationRecords( + records: MedicationRecord[], + query: string, + limit = 50, + // Low-weight synonym/acronym/alias terms (e.g. from analyzeClinicalQuery) threaded into the + // shared ranker's expanded lane: they add recall via the content haystack without competing + // with exact name/prefix scoring. Empty by default so existing callers are unchanged. + expansions: string[] = [], +): MedicationSearchMatch[] { + return rankCatalogRecords(records, query, { + fields: [ + { + id: "name", + weight: 8, + text: (medication) => normalizeSearchText(`${medication.name} ${medication.slug}`), + }, + { + id: "taxonomy", + weight: 3, + text: (medication) => + normalizeSearchText( + [medication.class, medication.subclass, medication.category, medication.tag, medication.schedule].join(" "), + ), + }, + ], + fullText: medicationSearchText, + contentWeight: 2, + compactBonus: 6, + compactExtraText: (medication) => normalizeSearchText(medication.name), + phraseBonus: 4, + exactValues: (medication) => [normalizeSearchText(medication.name), normalizeSearchText(medication.slug)], + exactBonus: 10, + prefixValues: (medication) => [normalizeSearchText(medication.name), normalizeSearchText(medication.slug)], + prefixBonus: 5, + expandTokens: expansions.length ? (terms) => [...terms, ...expansions] : undefined, + limit, + tieBreak: (left, right) => left.name.localeCompare(right.name), + }).map(({ record, score, signals }) => ({ + medication: record, + score, + reasons: [ + signals.fields.name ? "name" : "", + signals.prefix ? "name prefix" : "", + signals.compact ? "exact name" : "", + signals.fields.taxonomy ? "class/category" : "", + signals.content ? "content" : "", + ].filter(Boolean), + })); +} + +export { medicationIdentityBadges } from "@/lib/medication-badges"; + +export function medicationDetailTiles(record: MedicationRecord) { + const usualDose = medicationUsualDose(record); + const ceiling = medicationCeiling(record); + const avoid = medicationAction(record); + return [ + { + label: "Prescribing answer", + value: medicationIndication(record).split(".")[0] ?? record.name, + meta: record.subclass || record.category, + }, + { + label: "Dosing", + value: usualDose, + meta: record.stats[0]?.label ?? "Usual dose", + }, + { + label: "Dose ceiling", + value: ceiling, + meta: "MAX", + }, + { + label: "Avoid", + value: avoid?.split(",")[0] ?? "Review contraindications", + meta: record.schedule === "S8" ? "Controlled" : "Safety", + danger: true, + }, + ]; +} diff --git a/src/lib/semantic-tone.ts b/src/lib/semantic-tone.ts new file mode 100644 index 000000000..36ebd1d55 --- /dev/null +++ b/src/lib/semantic-tone.ts @@ -0,0 +1,98 @@ +// Canonical semantic tone system for badges, chips, and compact status labels. +// +// This is the single source of truth for the six clinical badge tones described +// in `docs/clinical-badge-system-guide.md`. It is intentionally framework-free +// (no JSX, no lucide runtime) so server code, the worker, and tests can import +// tone priority/meaning without pulling in the React render layer. The render +// layer (`src/components/clinical-dashboard/clinical-badge.tsx`) maps these tones +// to token classes and icons. + +export type SemanticTone = "neutral" | "clinical" | "success" | "warning" | "danger" | "info"; + +// Highest urgency first. Used to order badge clusters so the most important +// safety signal is never truncated away behind passive metadata. +export const SEMANTIC_TONE_PRIORITY: Record = { + danger: 6, + warning: 5, + clinical: 4, + success: 3, + neutral: 2, + info: 1, +}; + +// Tones in descending priority order (danger → info). Handy for legends/tests. +export const SEMANTIC_TONES: readonly SemanticTone[] = ["danger", "warning", "clinical", "success", "neutral", "info"]; + +// Semantic icon keys resolved to Lucide components at the render boundary. Kept +// as strings here so data modules (medication badges, the flag catalogue) can +// name an icon without depending on lucide-react. +export const SEMANTIC_ICON_KEYS = ["danger", "warning", "controlled"] as const; +export type SemanticIconKey = (typeof SEMANTIC_ICON_KEYS)[number]; + +export type SemanticToneMeta = { + /** Human-facing tone name for legends and docs. */ + label: string; + /** What the tone means / when to use it. */ + meaning: string; + /** + * Short prefix announced to assistive tech before the badge label so meaning + * survives without colour, e.g. "Do not use: Cr >120 avoid". Empty for tones + * whose label already reads plainly and carry no urgency. + */ + ariaPrefix: string; + /** + * Whether the tone renders a default status icon so it is distinguishable + * without colour (forced-colors / colour-blind). Only the two safety tones + * opt in; the rest stay quiet per the guide ("icon only when useful"). + */ + defaultIcon: boolean; +}; + +export const SEMANTIC_TONE_META: Record = { + danger: { + label: "Danger", + meaning: "Stop, avoid, contraindicated, failed, outdated, or unsafe.", + ariaPrefix: "Do not use", + defaultIcon: true, + }, + warning: { + label: "Warning", + meaning: "Pause, check, adjust, review, or interpret with caution.", + ariaPrefix: "Caution", + defaultIcon: true, + }, + clinical: { + label: "Clinical", + meaning: "A clinical action or instruction to carry out. Not a trust or safety signal.", + ariaPrefix: "", + defaultIcon: false, + }, + success: { + label: "Success", + meaning: "Confirmed, current, reviewed, available, or source-backed. Not clinical safety.", + ariaPrefix: "", + defaultIcon: false, + }, + neutral: { + label: "Neutral", + meaning: "Reference metadata or a passive fact that needs no action.", + ariaPrefix: "", + defaultIcon: false, + }, + info: { + label: "Info", + meaning: "System or process state. Rare in clinical content.", + ariaPrefix: "", + defaultIcon: false, + }, +}; + +/** + * Stable, priority-sorted copy (highest urgency first). Insertion order is + * preserved within a tone, matching the previous medication badge behaviour. + */ +export function sortBySemanticTonePriority(items: T[]): T[] { + return [...items].sort( + (left, right) => SEMANTIC_TONE_PRIORITY[right.tone ?? "neutral"] - SEMANTIC_TONE_PRIORITY[left.tone ?? "neutral"], + ); +} diff --git a/tests/catalog-search.test.ts b/tests/catalog-search.test.ts new file mode 100644 index 000000000..c788eff50 --- /dev/null +++ b/tests/catalog-search.test.ts @@ -0,0 +1,122 @@ +import { describe, expect, it } from "vitest"; +import { compactSearchText, normalizeSearchText, rankCatalogRecords } from "../src/lib/catalog-search"; + +type Item = { title: string; slug: string; tags: string[]; body: string }; + +const items: Item[] = [ + { title: "Clozapine Monitoring", slug: "clozapine-monitoring", tags: ["antipsychotic"], body: "ANC FBC thresholds" }, + { title: "Lithium Levels", slug: "lithium-levels", tags: ["mood stabiliser"], body: "Serum level monitoring" }, + { title: "Transfer Checklist", slug: "transfer-checklist", tags: ["transport"], body: "Receiving service details" }, +]; + +function rank(query: string, overrides: Partial>[2]> = {}) { + return rankCatalogRecords(items, query, { + fields: [ + { id: "title", weight: 6, text: (item) => normalizeSearchText(`${item.title} ${item.slug}`) }, + { id: "tags", weight: 3, text: (item) => normalizeSearchText(item.tags.join(" ")) }, + ], + fullText: (item) => normalizeSearchText(`${item.title} ${item.tags.join(" ")} ${item.body}`), + ...overrides, + }); +} + +describe("normalizeSearchText (shared)", () => { + it("keeps dose-string characters that the retired per-domain normalizers disagreed on", () => { + expect(normalizeSearchText("0.5mg IM/PO 5+5 co-located")).toBe("0.5mg im/po 5+5 co-located"); + }); + + it("strips diacritics and collapses punctuation to single spaces", () => { + expect(normalizeSearchText("Sérum; Lévels!")).toBe("serum levels"); + }); + + it("compacts whitespace for compact-query matching", () => { + expect(compactSearchText("clozapine monitoring")).toBe("clozapinemonitoring"); + }); +}); + +describe("rankCatalogRecords", () => { + it("returns nothing for an empty or whitespace query", () => { + expect(rank("")).toEqual([]); + expect(rank(" ")).toEqual([]); + }); + + it("weights field matches by their configured weight plus the content weight", () => { + const [top] = rank("clozapine"); + expect(top.record.slug).toBe("clozapine-monitoring"); + // title (6) + content (2) + whole-query phrase (4) — a single-term query IS its own + // phrase, matching the historical per-domain rankers. + expect(top.score).toBe(12); + expect(top.signals.fields.title).toBe(1); + expect(top.signals.content).toBe(1); + expect(top.signals.phrase).toBe(true); + }); + + it("drops records with no matching signal", () => { + const results = rank("clozapine"); + expect(results.some((match) => match.record.slug === "lithium-levels")).toBe(false); + }); + + it("applies the whole-phrase bonus on top of term matches", () => { + const [top] = rank("clozapine monitoring"); + // 2 title terms (12) + 2 content terms (4) + phrase (4). + expect(top.score).toBe(20); + expect(top.signals.phrase).toBe(true); + }); + + it("grants the exact bonus only on strict equality with a configured exact value", () => { + const options = { + exactValues: (item: Item) => [normalizeSearchText(item.title), normalizeSearchText(item.slug)], + exactBonus: 10, + }; + const exact = rank("clozapine monitoring", options)[0]; + const partial = rank("clozapine", options)[0]; + expect(exact.signals.exact).toBe(true); + expect(partial.signals.exact).toBe(false); + expect(exact.score).toBe(30); + }); + + it("grants the compact bonus when the de-spaced query appears in the compacted haystack", () => { + const [top] = rank("clozapinemonitoring", { compactBonus: 6 }); + expect(top.signals.compact).toBe(true); + // The de-spaced term matches nothing term-wise; only the compact bonus scores it, + // which is exactly how a run-together query survived in the historical rankers. + expect(top.score).toBe(6); + }); + + it("adds the broad-catalogue bonus to every record when a broad term is present", () => { + const results = rank("transport checklist", { broadTerms: ["transport"], broadBonus: 1 }); + expect(results[0].record.slug).toBe("transfer-checklist"); + for (const match of results) expect(match.signals.broad).toBe(true); + }); + + it("expands query terms through the expandTokens hook", () => { + const results = rank("cloz", { + expandTokens: (terms) => (terms.includes("cloz") ? [...terms, "clozapine"] : terms), + }); + expect(results[0].record.slug).toBe("clozapine-monitoring"); + }); + + it("breaks score ties by input order unless a tieBreak is supplied", () => { + const tied: Item[] = [ + { title: "Zeta Monitoring", slug: "zeta", tags: [], body: "" }, + { title: "Alpha Monitoring", slug: "alpha", tags: [], body: "" }, + ]; + const byInput = rankCatalogRecords(tied, "monitoring", { + fields: [{ id: "title", weight: 6, text: (item) => normalizeSearchText(item.title) }], + fullText: (item) => normalizeSearchText(item.title), + }); + expect(byInput.map((match) => match.record.slug)).toEqual(["zeta", "alpha"]); + + const byTitle = rankCatalogRecords(tied, "monitoring", { + fields: [{ id: "title", weight: 6, text: (item) => normalizeSearchText(item.title) }], + fullText: (item) => normalizeSearchText(item.title), + tieBreak: (left, right) => left.title.localeCompare(right.title), + }); + expect(byTitle.map((match) => match.record.slug)).toEqual(["alpha", "zeta"]); + }); + + it("applies the limit after ranking", () => { + const results = rank("monitoring checklist", { limit: 1 }); + expect(results).toHaveLength(1); + }); +}); diff --git a/tests/cross-mode-links.test.ts b/tests/cross-mode-links.test.ts new file mode 100644 index 000000000..cc79b5c87 --- /dev/null +++ b/tests/cross-mode-links.test.ts @@ -0,0 +1,141 @@ +import { describe, expect, it } from "vitest"; + +import { crossModeDifferentialCatalog } from "@/lib/cross-mode-differentials"; +import { buildCrossModeLinks, buildCrossModeLinksForThread } from "@/lib/cross-mode-links"; +import { extractKeywordTerms, keywordQueryFromNaturalLanguage } from "@/lib/keyword-query"; +import { defaultMedicationRecords } from "@/lib/medication-fixtures"; +import type { ServiceRecord } from "@/lib/services"; + +const medications = defaultMedicationRecords(); +const differentials = crossModeDifferentialCatalog(); + +const homeTreatmentTeam: ServiceRecord = { + slug: "adult-home-treatment-team", + title: "Adult Home Treatment Team", + subtitle: "Intensive home-based acute care", + statusChips: [{ label: "Acute", tone: "info" }], + tags: ["home treatment"], +}; + +// Matches "adult" and "treatment" via tags only — must stay below the +// title-reason gate no matter how many tag/content points it accumulates. +const tagOnlyService: ServiceRecord = { + slug: "crisis-line", + title: "Crisis Line", + tags: ["adult", "treatment"], +}; + +describe("extractKeywordTerms", () => { + it("normalizes, strips stop words, and dedupes", () => { + expect(extractKeywordTerms("What is the max dose of clozapine?")).toEqual(["what", "max", "dose", "clozapine"]); + expect(extractKeywordTerms("dose dose DOSE")).toEqual(["dose"]); + expect(extractKeywordTerms("the of and to a is")).toEqual([]); + }); + + it("caps terms and keeps the legacy 7-term keyword query behavior", () => { + const long = Array.from({ length: 15 }, (_, index) => `token${index}`).join(" "); + expect(extractKeywordTerms(long)).toHaveLength(12); + expect(keywordQueryFromNaturalLanguage(long).split(" ")).toHaveLength(7); + }); +}); + +describe("buildCrossModeLinks", () => { + it("links a full question to the named medication", () => { + const links = buildCrossModeLinks("what is the max dose of clozapine", { medications }); + expect(links).toHaveLength(1); + expect(links[0]).toMatchObject({ + modeId: "prescribing", + slug: "clozapine", + detailHref: "/medications/clozapine", + modeSearchQuery: "Clozapine", + }); + expect(links[0]!.modeLabel).toBe("Medication"); + expect(links[0]!.matchReason).toContain("name"); + }); + + it("returns nothing for question filler that only content-matches records", () => { + expect(buildCrossModeLinks("what is the maximum dose", { medications, differentials })).toEqual([]); + }); + + it("links services on title matches and rejects tag-only matches", () => { + const links = buildCrossModeLinks("how do I refer to the adult home treatment team", { + services: [homeTreatmentTeam, tagOnlyService], + }); + expect(links).toHaveLength(1); + expect(links[0]).toMatchObject({ + modeId: "services", + slug: "adult-home-treatment-team", + detailHref: "/services/adult-home-treatment-team", + subtitle: "Intensive home-based acute care", + }); + expect(links[0]!.badges).toEqual([{ label: "Acute", tone: "info" }]); + expect(links[0]!.modeSearchHref).toContain("/services?"); + expect(links[0]!.modeSearchHref).toContain("run=1"); + }); + + it("links differentials via alias expansion", () => { + const links = buildCrossModeLinks("how do I manage an acutely psychotic patient", { differentials }); + expect(links).toHaveLength(1); + expect(links[0]!.modeId).toBe("differentials"); + expect(links[0]!.title.toLowerCase()).toMatch(/psychosis|psychotic/); + expect(links[0]!.detailHref).toMatch(/^\/differentials\/(diagnoses|presentations)\//); + }); + + it("does not surface differentials for queries that only name a medication", () => { + const links = buildCrossModeLinks("acamprosate renal dosing", { medications, differentials }); + expect(links.length).toBeGreaterThan(0); + expect(links.every((link) => link.modeId === "prescribing")).toBe(true); + }); + + it("caps per-mode and total results", () => { + const sleepClinic = (slug: string, title: string): ServiceRecord => ({ slug, title }); + const services = [ + sleepClinic("sleep-clinic-north", "Sleep Clinic North"), + sleepClinic("sleep-clinic-south", "Sleep Clinic South"), + sleepClinic("sleep-clinic-east", "Sleep Clinic East"), + ]; + const forms = [ + sleepClinic("sleep-referral-form", "Sleep Clinic Referral"), + sleepClinic("sleep-review-form", "Sleep Clinic Review"), + sleepClinic("sleep-audit-form", "Sleep Clinic Audit"), + ]; + + const links = buildCrossModeLinks("sleep clinic", { services, forms }); + expect(links).toHaveLength(4); + expect(links.filter((link) => link.modeId === "services")).toHaveLength(2); + expect(links.filter((link) => link.modeId === "forms")).toHaveLength(2); + + const capped = buildCrossModeLinks("sleep clinic", { services, forms }, { maxTotal: 3 }); + expect(capped).toHaveLength(3); + }); + + it("dedupes a slug shared between the services and forms registries", () => { + const shared: ServiceRecord = { slug: "shared-pathway", title: "Shared Pathway" }; + const links = buildCrossModeLinks("shared pathway", { services: [shared], forms: [shared] }); + expect(links).toHaveLength(1); + expect(links[0]!.modeId).toBe("services"); + }); + + it("keeps entity links alive across multiple entity-free follow-up turns", () => { + const thread = ["what is the max dose of clozapine", "what about renal impairment", "and in elderly patients"]; + const links = buildCrossModeLinksForThread(thread, { medications }); + expect(links).toHaveLength(1); + expect(links[0]).toMatchObject({ modeId: "prescribing", slug: "clozapine" }); + }); + + it("prefers the newest turn that names an entity", () => { + const thread = ["what is the max dose of clozapine", "tell me about acamprosate"]; + const links = buildCrossModeLinksForThread(thread, { medications }); + expect(links).toHaveLength(1); + expect(links[0]!.slug).toBe("acamprosate"); + + expect(buildCrossModeLinksForThread([], { medications })).toEqual([]); + expect(buildCrossModeLinksForThread(["what about renal impairment", null], { medications })).toEqual([]); + }); + + it("returns nothing for empty or stop-word-only queries and empty catalogs", () => { + expect(buildCrossModeLinks("", { medications })).toEqual([]); + expect(buildCrossModeLinks("the of and", { medications })).toEqual([]); + expect(buildCrossModeLinks("clozapine dose", {})).toEqual([]); + }); +}); diff --git a/tests/medication-badges.test.ts b/tests/medication-badges.test.ts new file mode 100644 index 000000000..447c3d0f6 --- /dev/null +++ b/tests/medication-badges.test.ts @@ -0,0 +1,145 @@ +import { describe, expect, it } from "vitest"; + +import { getMedicationRecord, loadMedicationSnapshot } from "@/lib/medication-snapshot"; +import { + medicationAccessBadges, + medicationIdentityBadges, + medicationRowBadges, + medicationStatTone, +} from "@/lib/medication-badges"; +import { deriveGovernanceFromSections } from "@/lib/medication-records"; +import type { MedicationRecord } from "@/lib/medications"; + +describe("medication badge mappers", () => { + const acamprosate = getMedicationRecord("acamprosate"); + if (!acamprosate) throw new Error("acamprosate fixture missing"); + + it("maps acamprosate identity badges from snapshot fields", () => { + const governance = deriveGovernanceFromSections(acamprosate); + const badges = medicationIdentityBadges(acamprosate, { + sourceStatus: governance.source_status, + validationStatus: governance.validation_status, + }); + const labels = badges.map((badge) => badge.label); + + expect(labels).toContain("AUD"); + expect(labels).toContain("S4"); + expect(labels).toContain("Campral"); + expect(labels).toContain("333 mg EC tablet"); + expect(labels).toContain("PBS streamlined"); + expect(labels).toContain("PBS"); + expect(labels).toContain("TGA"); + expect(labels).toContain("Reviewed"); + expect(badges.some((badge) => badge.label === "8357W")).toBe(true); + }); + + it("maps contra absolute row badges from patient metadata", () => { + const contraSection = acamprosate.sections.find((section) => section.type === "contra"); + const absoluteRow = contraSection?.rows.find((row) => row.key === "Absolute"); + expect(absoluteRow).toBeTruthy(); + + const badges = medicationRowBadges(absoluteRow!, "contra"); + expect(badges.some((badge) => badge.label === "Cr >120 avoid" || badge.label === "Renal")).toBe(true); + expect(badges.every((badge) => badge.tone === "danger" || badge.tone === "warning")).toBe(true); + }); + + it("maps dose renal impairment row badges", () => { + const doseSection = acamprosate.sections.find((section) => section.type === "dose"); + const renalRow = doseSection?.rows.find((row) => row.key === "Renal Impairment"); + expect(renalRow).toBeTruthy(); + + const badges = medicationRowBadges(renalRow!, "dose"); + expect(badges.some((badge) => badge.label === "Renal adjustment" || badge.label === "Contraindicated")).toBe(true); + }); + + it("maps risk gastrointestinal severity badge", () => { + const riskSection = acamprosate.sections.find((section) => section.type === "risk"); + const giRow = riskSection?.rows.find((row) => row.key === "Gastrointestinal"); + expect(giRow).toBeTruthy(); + + const badges = medicationRowBadges(giRow!, "risk"); + expect(badges.some((badge) => badge.label === "High")).toBe(true); + expect(badges.find((badge) => badge.label === "High")?.tone).toBe("warning"); + }); + + it("maps access badges for acamprosate", () => { + const badges = medicationAccessBadges(acamprosate); + expect(badges.some((badge) => badge.label === "Campral")).toBe(true); + expect(badges.some((badge) => badge.label.includes("8357W"))).toBe(true); + expect(badges.some((badge) => badge.label === "PBS streamlined")).toBe(true); + }); + + it("maps stat cls and flag to tones", () => { + const maxDose = acamprosate.stats.find((stat) => stat.label.includes("Max Dose")); + const renalAdj = acamprosate.stats.find((stat) => stat.label.includes("Renal")); + expect(maxDose).toBeTruthy(); + expect(renalAdj).toBeTruthy(); + expect(medicationStatTone(maxDose!)).toBe("danger"); + expect(medicationStatTone(renalAdj!)).toBe("warning"); + }); + + it("keeps badge lists stable across the full snapshot corpus", () => { + const records = loadMedicationSnapshot(); + + for (const record of records) { + const governance = deriveGovernanceFromSections(record); + const identityBadges = medicationIdentityBadges(record, { + sourceStatus: governance.source_status, + validationStatus: governance.validation_status, + }); + + expect(identityBadges.length).toBeLessThanOrEqual(12); + expect(new Set(identityBadges.map((badge) => badge.id)).size).toBe(identityBadges.length); + + for (const section of record.sections) { + for (const row of section.rows) { + const rowBadges = medicationRowBadges(row, section.type); + expect(rowBadges.length).toBeLessThanOrEqual(4); + expect(new Set(rowBadges.map((badge) => badge.id)).size).toBe(rowBadges.length); + } + } + } + }); +}); + +describe("medications catalogue regression", () => { + it("exposes PBS streamlined on acamprosate identity badges", () => { + const record = getMedicationRecord("acamprosate"); + expect(record).toBeTruthy(); + const badges = medicationIdentityBadges(record!); + expect(badges.some((badge) => badge.label === "PBS streamlined")).toBe(true); + }); +}); + +describe("controlled-drug (S8) schedule badge", () => { + const baseRecord: MedicationRecord = { + slug: "test-schedule", + name: "Test Schedule", + class: "", + subclass: "", + category: "", + accent: "#0f766e", + tag: "", + schedule: "S8", + stats: [], + sections: [], + quick: [], + }; + + it("shows S8 as a controlled warning with a lock icon, never danger", () => { + const badges = medicationIdentityBadges(baseRecord); + const scheduleBadge = badges.find((badge) => badge.label === "S8"); + expect(scheduleBadge).toBeTruthy(); + expect(scheduleBadge?.tone).toBe("warning"); + expect(scheduleBadge?.iconKey).toBe("controlled"); + // Regulatory scheduling must not consume the danger tone reserved for stops. + expect(badges.every((badge) => badge.tone !== "danger")).toBe(true); + }); + + it("keeps non-S8 schedules as plain info metadata", () => { + const badges = medicationIdentityBadges({ ...baseRecord, schedule: "S4" }); + const scheduleBadge = badges.find((badge) => badge.label === "S4"); + expect(scheduleBadge?.tone).toBe("info"); + expect(scheduleBadge?.iconKey).toBeUndefined(); + }); +}); diff --git a/tests/ui-smoke.spec.ts b/tests/ui-smoke.spec.ts index 07a07c98f..db3997fef 100644 --- a/tests/ui-smoke.spec.ts +++ b/tests/ui-smoke.spec.ts @@ -1,6 +1,9 @@ import type { Route } from "playwright-core"; import { expect, test, type Locator, type Page } from "playwright/test"; import { demoAnswer, demoDocuments, getDemoDocument, getDemoDocumentPayload } from "../src/lib/demo-data"; +import { deriveGovernanceFromSections } from "../src/lib/medication-records"; +import { getMedicationRecord, loadMedicationSnapshot } from "../src/lib/medication-snapshot"; +import { medicationToSearchResult, rankMedicationRecords } from "../src/lib/medications"; const dashboardViewports = [ { name: "small-mobile", width: 320, height: 720 }, @@ -196,6 +199,48 @@ async function mockDemoApi(page: Page, options: { answerOverride?: DemoAnswerOve }, }); }); + await page.route(/\/api\/medications(?:\/([^/?]+))?(?:\?.*)?$/, async (route) => { + const url = new URL(route.request().url()); + const slug = url.pathname.match(/\/api\/medications\/([^/]+)$/)?.[1]; + if (slug) { + const record = getMedicationRecord(decodeURIComponent(slug)); + if (!record) { + await route.fulfill({ status: 404, json: { error: `No medication found for "${slug}".` } }); + return; + } + const governance = deriveGovernanceFromSections(record); + await route.fulfill({ + json: { + record, + governance: { + sourceStatus: governance.source_status, + validationStatus: governance.validation_status, + }, + demoMode: true, + }, + }); + return; + } + + const query = url.searchParams.get("q")?.trim() || undefined; + const limit = Number(url.searchParams.get("limit") ?? "50"); + const records = loadMedicationSnapshot(); + const matches = query ? rankMedicationRecords(records, query, limit) : undefined; + await route.fulfill({ + json: { + records, + matches: matches?.map((match) => ({ + medication: match.medication, + result: medicationToSearchResult(match), + score: match.score, + reasons: match.reasons, + })), + total: records.length, + governance: {}, + demoMode: true, + }, + }); + }); await page.route(/\/api\/ingestion\/jobs(?:\?.*)?$/, async (route) => { await route.fulfill({ json: { jobs: [], demoMode: true } }); }); @@ -1159,6 +1204,40 @@ test.describe("Clinical KB UI smoke coverage", () => { await expectNoPageHorizontalOverflow(page); }); + test("answer results surface cross-mode quick links", async ({ page }) => { + await page.setViewportSize({ width: 1280, height: 900 }); + await mockDemoApi(page); + const question = "What is the maximum dose of clozapine?"; + await page.goto(`/?mode=answer&q=${encodeURIComponent(question)}&run=1`, { + waitUntil: "domcontentloaded", + }); + await expect(page.getByTestId("plain-answer-response")).toBeVisible({ timeout: uiAssertionTimeoutMs }); + + await expect(page.getByTestId("cross-mode-links")).toHaveCount(1, { timeout: 15_000 }); + + const answerSurface = page.locator('[data-dashboard-stage="answer-surface"]'); + const strip = answerSurface.getByTestId("cross-mode-links"); + await expect(strip).toBeVisible(); + await page.keyboard.press("Escape"); + await expect(strip.getByText("Medication", { exact: true })).toBeVisible(); + await expect(strip.getByRole("button", { name: "Search Clozapine in Medication" })).toBeVisible(); + + const followUps = answerSurface.getByTestId("answer-follow-up-suggestions"); + if (await followUps.isVisible()) { + const stripBox = await strip.boundingBox(); + const followUpBox = await followUps.boundingBox(); + expect(stripBox).toBeTruthy(); + expect(followUpBox).toBeTruthy(); + expect(stripBox!.y).toBeLessThan(followUpBox!.y); + } + + const medicationLink = strip.getByRole("link", { name: "Clozapine", exact: true }); + await expect(medicationLink).toHaveAttribute("href", "/medications/clozapine"); + await medicationLink.click(); + await expect(page).toHaveURL(/\/medications\/clozapine/, { timeout: 15_000 }); + await expectNoPageHorizontalOverflow(page); + }); + test("answer mode keeps prior turns visible for follow-up questions", async ({ page }) => { await page.setViewportSize({ width: 390, height: 820 }); await mockDemoApi(page);