Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Update 2013- Drug Therapy during Holy Month of Ramadan Yousef A. Alomi, Bsc, Msc., BCPS, BCNSP, DiBA [email protected] [email protected] Head, National Drug Information Center Head, General Adminstration of Pharmaceutical Care Consultant Clinical Pharmacist Ministery of Health Islam was built based on five billers (the statement of Faith, prayers of five times daily, charity to poor people, and Fasting of one Month yearly called Ramadan, and pillgrime to Mecca once in a lif). Fasting the holy Month of Ramadan is stop taking or ingection any food or drinks from sunrise to sunset, this madate to all adults either male or female, unless tarvelers, risk dangrous of pregrant and lactatin women, and elderly can not tolerate the fasting, and sick people In Islam the Sick people allow them to break fasting, then postbond fasting next month if the illness is temporary. If the illnees perment and the patinet can not fast at all she or he to pay money to poor people as subsiture of fasting for each day breaking fasting. Not all the illnesses are allowable to break fasting, its only if the fasting affect the patients health negatively, otherwise; if the patient can fast she or he to fast Ramadan. The problem is raising of medications for chronic disaeses , how can I switch from regular days time to Fasting Days Times, at what time excatly, does the fasting some medication and increase or decrease their activity, is there any changes in pharmacokinetics of medications, does the food affect absorption of medication after peoriod of fasting, all thease question we try to answer them in the remaining of this paper It estimated there are 1.1–1.5 billion Muslims worldwide, Most Muslims would like not to break fasting, even the fasting will affect their health. Some studies showed that Muslims receiving medical treatment during Ramadan will deliberately not taken tablets or other medicine at the prescribed time if that falls drug the day light hours, or alternatively will overdose during night to makeup for missed day time doses. A study 1 by Aslam M, et.al , reported that 37 (45.7%) patients of 81 were found to change their drug dosage pattern while fasting; 35 (43.2%) missed doses; 8 (9.8%)took their tablets at different times and 4 (4.9%) patients took all their medication as one single daily dose after breaking fast in the evening. Another survey 2 of 325 outpatients in a Kuwaiti hospital found that most of them changed their drug regimens during Ramadan. Sixty four per cent of the patients changed their therapeutic scheme during the month; 18% took their daily medicines in a single intake, either before the first meal (sunset) or straight after the last one (before dawn). Another hospital-based study of 334 patients conducted in during the month of Ramadan in 2006 to illustrate thevarious characteristics including care of patients and changes in lifestyle of type 2 diabetics during Ramadan in Dhahira region, Oman. Most of the type 2 diabetes patients in the study (93.1%) fasted 30 days during Ramadan. It was noticed that nearly 83% of the type 2 diabetes patients in our study had poorly controlled FBS levels (83.2%). Insulin/Oral Anti Diabetic Drug (OAD) doses were unchanged in 49.5% of diabetic patients during Ramadan. 3 Some authors reported that two patients with chronic reversible respiratory disease were admitted to an intensive care unit two weeks after the start of Ramadan, Both patients admitted due to not having taken their treatment, including inhalers, during daylight hours. Another study evaluated the changes in frequency of seizures during Ramadan in 124 patients with idiopathic epilepsy, seizures occurred in 27 patients during this month; 20 of them did not use any antiepileptic drugs from dawn to sunset. The author concluded that withdrawal of drugs was the most important cause of recurrence of epilepsy during Ramadan. 4 A recent study of wide population-based Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study, which showed (in 12,243 people with diabetes from 13 Islamic countries) 43% of patients of type 1 diabetes, and 79% of patients with type 2 diabetes were fasting during Ramadan; with an estimation of 40–50 million people with diabetes worldwide , and 3.6 1,9 Million in Saudi Arabia will fast during Ramadan, 5-7 Although all previous studies, with patients perception and attitude toward their medications, and dangerous impact of their diseases; there is no consensus guideline of drug therapy during. Recommendation drug therapy regimen for the disaeses during fasting is very difficult, due to very little experiences, and no clinical trials about drug fasting during Ramadan or pharmacokinetics of drugs during fasting. It is not appropriate to change the drug regimen, or dose from several dose per day to two big dose once or twice daily without scientific evidence that alternative dose is equivalence in efficacy and safety. Further, the patient should stabilized with the new drug or dose before or during Ramadan. Here are some advices and recommendations by some authors to explore Drug Therapy During Ramadan as following: General Recommendation • • • • • • • • • • • • • • • • • • Mark Ramadan on your office calendar, and prepare to be the one that brings up the topic for discussion. Patients are unlikely to initiate the discussion. Ask about the patient’s beliefs regarding fasting, his/her illness, and the use of oral and injectable drugs when fasting. Inquire about current control of symptoms and comorbidities. Inquire about past experiences during Ramadan fasts, and plans for the upcoming Ramadan. Provide information and Medical education about his or her mental illness as medical, physically-mediated illness Clearly communicate risks of medication changes, changes in sleeping and eating schedules, and withdrawal from substances. Explain that decision is ultimately the patient’s, but you can advise him/her and help maximize chances of fasting safely. Give general preference to medications that will allow for the easiest compliance during Ramadan, e.g. slow-release preparations, longer elimination half-lives, and once daily dosing. Consider a switch to slow-release or once-daily medications for the month of Ramadan. These forms may more expensive, and may require some planning ahead, but it may be worth a switch for some patients. Recommend dosing schedules coincident with pre-dawn (Suhoor) and sunset (Iftar) meals. Recommend refraining from fasting according to Islamic rules for those that must take medications at a frequency of more than twice a day. Work to find creative compromises, balancing the patients’ preferences and your knowledge of the risks and benefits of possible plans. If a patient insists on discontinuing medications, plan a taper in advance. Recommend tapering use of caffeine and nicotine in the weeks before Ramadan to avoid unpleasant withdrawal syndromes. Encourage a moderate amount of physical activity; too much exertion may contribute to dehydration, but some activity is better than a completely sedentary month. Encourage patient to bring up the issue with their primary care doctor, to discuss which medications may be amenable to change in dosing schedule. Consult an imam of masijid or Shiek with help in interpreting rules, and in communicating with and reassuring the patient. Arrange for follow-up appointments during Ramadan and when concerns arise. Fasting and Drug dosing schedule There are many drugs can given to the patient without affecting fasting Ramadan or nullify fasting, accoring “An Islamic view of certain contemporary medical issues” that was in Morocco 1997; for instant 8 1. Eye and ear drops 2. All substances absorbed into the body through the skin,such as creams,ointments,and medicated plasters 3. Insertion into the vagina of pessaries, medical ovules, and vaginal washes 4. Injections through the skin, muscle, joints, or veins, with the exception of intravenous feeding 5. Oxygen and anaesthetic gases 6. Mouthwash, gargle, or oral spray, provided nothing is swallowed into the stomach. 7. Nose drops, nose sprays, and inhalers 8. Anal injections Any medication can be enjection through mouth and reach to stomach break fasting. Health care provider can help mulsim patient if he wish to fasting eith The Holy Month of Ramadan or any Holy Days throug the year, by changing admintartiom time instead of three or fout time a day and switch to tiwce or once aday without Break-Fast. In Ramadan, instead of morning and evening, it needs to change to dawn and sunset respectively. Twice daily dose can be taken on 04:30, and 19:00 special in this year 2013 for Riyadh time, Saudi Arabia. Once daily dose can be taken on 04:30, or 19:00. We attached Up-to-date 2013 suggested table1 describe type of medication, affect of food, frequency of adminstration, preferable time of adminstration, and clinical evidence. An table 2 showed Medications, adult maintenance dose in the nornal renal function, and frequency per day, on regular day, and Medications, adult dose, and frequency per day as alternative during Ramadan, the doses stated for general indication, table 3 showed medications registration status at Saudi Food and Drug Authority and Ministry of Health Drug Formulary. The treating physcian or pharmacist should refer to other referances to doses for specific indications, and FDA or SFDA labeled indications during conversion to other medications. Any suggestion will be highly appreciated. Table 1 Medication During Holy Month of Ramadan 8,9 Type of Medication Adminstration Evidence Based Anti-Epileptic Drugs Once – Twice daily except Valoproic Acid The food: may decrease the absorption Time of admin: after 1-2 of Sun set (Iftar) Interchange: No, can be on specific situation General Evidence : No Evidence administration during Ramadan Specific Evidence: No Evidence of Pharmacokinetics during fasting Ramadan Anti-Psychiatrics Drugs Admin: Most of them Once daily, some are given Twice daily The food: may decrease the absorption Time of admin: pre-dawn (Suhoor) Interchange: No, can be on specific situation Admin: Once daily The food: may induce ulcer at empty stomach, and may reduce Warfarin Effect with vegitables Be carfull of taking large a mount of vitamin K, like broccoli, spinach, kale, turnip greens, cabbage, they may decrease the effect of drugs Aviod garlic, ginger, glucosamine, ginseng, and ginkgo may incraese the bleeding Time of admin: after Sun set (Iftar) Interchange: Switch Heparin to LMWH Admin: Once daily The food: No effects Time of admin: after Sun set (Iftar) Interchange: Switch to Statin therapy General Evidence : No Evidence administration during Ramadan, little evidence Specific Evidence: No Evidence of Pharmacokinetics during fasting Ramadan Antiplatelets and Anticoagulation Drugs Drug for Lipid Disorder General Evidence : No Evidence administration during Ramadan Specific Evidence: No Evidence of Pharmacokinetics during fasting Ramadan General Evidence : No Evidence administration during Ramadan Specific Evidence: No Evidence of Pharmacokinetics during fasting Ramadan Drug for Infectious Diseases Admin: Once – Twice daily The food: Variable Time of admin: after Sun set (Iftar) Interchange: Switch to long acting therapy General Evidence : No Evidence administration during Ramadan Specific Evidence: No Evidence of Pharmacokinetics during fasting Ramadan Drug for Asthma Admin: variable General Evidence : No Evidence administration The food: No effects except theophylline Using Bronchodilator with caffeine (Tea or Beverages) caan increase te chance of side eefctss, such excitability, nervousness, and rapid heart beat Time of admin: Any time Interchange: Switch to long acting therapy during Ramadan Specific Evidence: No Evidence of Pharmacokinetics during fasting Ramadan Drug for GIT Admin: Once daily The food: No effects Time of admin: pre-dawn (Suhoor) Interchange: Switch to long acting therapy General Evidence : No Evidence administration during Ramadan Specific Evidence: No Evidence of Pharmacokinetics during fasting Ramadan Drugs for Hypertension Admin: Once - Twice daily The food: No effects Aviod of taking ACE Inhibitors with latge a mount of Dates, Bananas, Oranges, green leafly vegetables General Evidence : No Evidence administration during Ramadan Specific Evidence: No Evidence of Pharmacokinetics during fasting Ramadan Time of admin: after Sun set (Iftar) Interchange: Most of drugs taking once ot twice daily, and if using short acting Switch to long acting therapy Drugs for Cardiac Arrhythmias Admin: Once daily The food: No effects Time of admin: after Sun set (Iftar) Interchange: Switch to long acting therapy General Evidence : No Evidence administration during Ramadan Specific Evidence: No Evidence of Pharmacokinetics during fasting Ramadan Drug for Pain Admin: Once daily The food: No effects Time of admin: after Sun set (Iftar) Interchange: Switch to long acting therapy General Evidence : No Evidence administration during Ramadan Specific Evidence: No Evidence of Pharmacokinetics during fasting Ramadan Medications During Fasting Program I do suggest to start this program specially during fating the holy month of Ramadan 1. 2. 3. 4. 5. 6. 7. 8. 9. Assinge Resposibility of one clinical pharmacist or trained qualify pharmacist Delnieate scope of services that wish you start with Define type of popultion and diaseses at starting point Setup protocols for each disaese drug therapy during regular and fasting days Start pilot study for certain period of time Collect the mearument data before and after the services Evaulaute the services and impact feedback Present results outcome to consern people medical and pharmacy staff Expand the scope of services and evalute it periodically References 1- Aslam M et. Al, Pharmacist, Medicines and the Fast of Ramadan, Pharm J, 259:12; 1997,973-75. 2- Aslam M, Assad A. Drug regimens and fasting during Ramadan: a survey in Kuwait. Public Health 1986;100:49-53. 3- Prakash Patel. et. al. Type 2 Diabetes and its characteristics during Ramadan in Dhahira region, Oman. Oman Medical Journal, 2007, Vol 22, No 3. 16-23 4- N Aadil, I E Houti and S Moussamih, Drug intake during Ramadan, BMJ , 2004;329;778-782 5- Al-arouj M. Et. al., Recommendations for Management of Diabetes During Ramadan, Diabetes Care, 2005, Vol 28 , No 9. 6- Salti I. et. al., A Population-Based Study of Diabetes and Its Characteristics During the Fasting Month of Ramadan in 13 Countries, Results of the Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study, Diabetes Care, 2004, Vol 27 , No 10. 7- Al-nozha M et al, Diabetes mellitus in Saudi Arabia, Saudi Med J 2004, Nov;25(11):1603-10 8- Aadil N, Houti IE, Moussamih S, Drug intake during Ramadan, BMJ 2004;329:778–82 9- Aviod Food Drug Interaction, A guide from National Consumer League and U.S. Food and Drug Adminstration; www.nclnet.org, or www.fda.gov/drugs, Publication no. (CDER 10-1933) 10- Al Salloum H.,The New Fluoroquinolones, Pharmacy Newsletter,10:2;1420. 11- Levabuterol for Asthma, The Medical Letter on Drug and Therapeutics, 41:4,1999 12- Al-Rasheed M, Proton-Pump Inhibitor, Pharmacy Newsletter,10:1;1420. 13- Saudi National Formulary, SPS & MOH, October 1995. 14- The Sixth Report of Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, Arch Inten Med, 157:24,1997,2413-2445. 15- Drugdex, Vol 137, Exp. September 2008, Micromedex Inc. 16- eBNF, British Medical Association and The Royal Pharmaceutical Society of Great Britain, No 37, march 1999. 17- Gilbert DN et al, The Sanford Guide to Antimicrobial Therapy, 29th Edition, 1999 18- Drugs for Chronic Obstructive Pulmonary Disease, Treatment Guidelines from The Medical Letter, 2007, Volume 5 (Issue 63): 95-100 19- Antiplatelet and Anticoagulant Drugs, Treatment Guidelines from The Medical Letter, 2008, Volume 6 (Issue 69): 29-36 20- Drugs for Epilepsy, Treatment Guidelines from The Medical Letter, 2012, Volume 11 (Issue 126): 9-19 21- Treatment of Peptic Ulcers and GERD, Treatment Guidelines from The Medical Letter, 2008, Volume 6 (Issue 72): 55-59 22- Drugs for Treatment of Chronic Heart Failure, Treatment Guidelines from The Medical Letter, 2012, Volume 10 (Issue 121): 69-72 23- Drugs for Hypertension, Treatment Guidelines from The Medical Letter, 2012, Volume 10 (Issue 113): 1-10 24- Antifungal Drugs, Treatment Guidelines from The Medical Letter, 2012, Volume 10 (Issue 120): 61-68 25- Drugs for Pain, Treatment Guidelines from The Medical Letter, 2013, Volume 11 (Issue 128): 31-42 26- Drugs for Acne,Rosacea, and Psoriasis, Treatment Guidelines from The Medical Letter, 2013, Volume 11 (Issue 125): 1-8 27- Drugs for Allergy Disorders, Treatment Guidelines from The Medical Letter, 2013, Volume 11 (Issue 129): 43-52 28- Drugs for Asthma, Treatment Guidelines from The Medical Letter, 2013, Volume 10 (Issue 114): 11-18 29- Drugs for Psychiatric Disorder, Treatment Guidelines from The Medical Letter, 2013, Volume 11 (Issue 130): 53-64 Table 2 No Drug therapy during Regular days 10-29 1. 2. 3. 4. 5. 6. 7. Regular Days Acebutolol Aliskiren Amiloride HCl Amitriptyline Amlodepine besylate Amoxicillin Aspirin 8. 9. 10. 11. 12. 13. 14. Atenolol Atorvastatine Aripiprazol Betoxalol Bisoprolol Candesartan Captopril 15. Carbamazepine Drug therapy during Holy Ramadan 10-29 Doses/ Day 200-1200 mg 150-300 mg 5-10 mg 50-150 mg 2.5- 10 mg 250- 500 mg 100 mg (prophylactic dose) 25-100 mg 10-80 mg 10-30 mg 5-40 mg 5-20 mg 8 -32 mg 12.5- 150 mg Frequency Per day Divided in 1-2 doses In 1 dose In 1-2 diveded dose In 1 dose or divided doses In 1 dose 3 times/day In 1 dose Regular Days Acebutolol Aliskiren Amiloride HCl Amitriptyline Amlodepine besylate Cotrimoxazole Aspirin In 1-2 doses In 1 dose In 1 dose In 1 dose In 1 dose In 1 dose Divided in 2-3 divided doses 800 –1600 mg (Blood Level 8-12 mcg/ml) In 2-3 divided doses Atenolol Atorvastatine Aripiprazol Betoxalol Bisoprolol Candesartan Enalapril Lisinopril Fosinopril Perindopril Quinapril Ramipril Trandolapril Carbamazepine Carbamazepine SR 16. 17. 18. 19. 20. 21. 22. 23. Carteolol Carvedilol Cefacolr Celeoxib Cephalexin Cerivastatin Chlorthalidone Cholestyramine 2.5-10 mg 12.5- 50 mg 250- 500 mg 200 mg 250 -500 mg 0.3mg 12.5- 50 mg 12-36 mg In 1 dose Divided in 2 doses 3 times 2 times 4 times In 1 dose In 1 dose Divided in 1- 4doses Carteolol Carvedilol Cefuroxim axitel Celeoxib Cefadroxil Cerivastatin Chlorthalidone Cholestyramine Doses/Day 200-1200mg 150-300 mg 5-10 mg 50-150 mg 2.5- 10 mg 490- 960 mg 100 mg (prophylactic dose) 25-100 mg 10-80 mg 10-30 mg 5-40 mg 5-20 mg 8 -32 mg 2.5 - 40 mg 5 - 40 mg 10-80 mg 4-8 mg 5-80 mg 1.25-20 mg 1-8 mg 800 – 1600 mg (Blood Level 8-12 mcg/ml) 800 – 1600 mg (Blood Level 8-12 mcg/ml) 2.5-10 mg 12.5- 50 mg 250- 500 mg 200 mg 500-1000 mg 0.3mg 12.5- 50 mg 12-36 mg Frequency Per day Divided in 1-2 doses In 1 dose In 1-2 diveded doses In 1 dose In 1 dose 2 times/day In 1 dose In 1-2 doses In 1 dose In 1 dose In 1 dose In 1 dose In 1 dose In 1-2 doses In 1 dose In 1-2 doses In 1-2 doses In 1-2 doses In 1-2 doses In 1-2 doses In 2 divided doses In 2 divided doses In 1 dose Divided in 2 doses 2 times 2 times 2 times In 1 dose In 1 dose In 1 dose 24. Cimitidine 25. 26. 27. 28. Ciprofloxacin Citalopram Clobazam Clonazepan 29. 30. 31. 32. 33. Clopidogrel Clonidine Cloxacillin Cotrimoxazole Dalteparin 34. Diclofenac 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. Diflunisal Digoxin Diltiazem HCl Doxazocin Mesylate Doxycyline Duloxetine Eplerenone Eprosartan Enalpril maleate Enoxaparin 45. Erythromycin 46. Ethosuximide 47. 48. 49. 50. 51. 52. 53. 54. Escitalopram Esomeprazole Felodipine Flucloxacillin Fluconazole Fluoxetine Folic acid Famotidine 400 800 mg 250-750 mg 20-40 mg 20-40 mg 1.5-8 mg 2 times In 1 dose 2 times In 1 dose In 1-2 divided doses In 2-3 divided doses Cimitidine 800 mg In 1 dose In 1 dose Divided in 2-3 doses 4 times 2 times/day In 1-2 doses Ciprofloxacin Citalopram Clobazam Clonazepan Clobazam Clopidogrel Clonidine Cefadroxil Cotrimoxazole Dalteparin 2 times In 1 dose In 1-2 divided doses In 2 divided doses In 1-2 divided doses In 1 dose Divided in 2 doses 2 times 2 times/day In 1-2 doses Divided in 3-4 dses 2 times Divided in 2-3 doses In 1 dose Divided in 3 doses In 1 dose Divided in 1-2 doses In 1 dose In 1-2 doses In 1-2 doses Divided in 1-2 doses In 1-2 doses Diclofenac Diclofenac SR Diflunisal Digoxin Diltiazem SR HCl Doxazocin Mesylate Doxycyline Duloxetine Eplerenone Eprosartan Enalpril maleate Enoxaparin 4 times Divided in 2 doses Clarithroycin Azithromycin Ethosuximide In 1 dose In 1 dose In 1 dose 4 times In 1 dose In 1 dose In 1 dose 2 times Escitalopram Esomeprazole Felodipine Cefadroxil Fluconazole Fluoxetine Folic acid Famotidine 250-750 mg 20-40 mg 20-40 mg 1.5-8 mg 20-40 mg 75 mg PO daily 0.1-0.6 mg 500-1000mg 490- 960 mg 5000-10,000 IU SC daily or q12h 75 mg 100 mg 500-1500 mg 0.125- 0.5 mg 120 -360 mg 1-16 mg 100-200 mg 60 mg 25-100 mg 400-800 mg 5- 40 mg 1 mg/kg bid or 1.5 mg/kg SC daily; 250-500 mg 500-1000 mg 750- 1250 mg (blood level 40-100 mcg/ml) 10-20 mg 20-40 mg 2.5- 10 mg 500-1000mg 50- 400 mg 10-20 mg 1- 5 mg 40 mg 75 mg PO daily 0.1-0.6 mg 250 -500 mg 490- 960 mg 5000-10,000 IU SC daily or q12h 50- 200mg 75 mg 500-1500 mg 0.125- 0.5 mg 60-360 mg 1-16 mg 100-200 mg 60 mg 25-100 mg 400-800 mg 5- 40 mg 1 mg/kg bid or 1.5 mg/kg SC daily; 250-500 mg 750- 1250 mg (blood level 40-100 mcg/ml) 10-20 mg 20-40 mg 2.5- 10 mg 250-500 mg 50- 400 mg 10-20 mg 1- 5 mg 20 mg 2 times In 1 dose Divided in 2-3 doses In 1 dose Divided in 1-2 doses In 1 dose Divided in 1-2 doses In 1 dose In 1-2 doses In 1-2 doses Divided in 1-2 doses In 1-2 doses 2 times 1 time Divided in 2 doses In 1 dose In 1 dose In 1 dose 2 times In 1 dose In 1 dose In 1 dose In 1 dose 55. 56. Fosinopril sodium Furosemide 57. Heparin (Unfractionated) 40 mg 10- 80 mg 20- 320 mg in 1 dose Divided in 1-2 doses Divided in 2 doses 60-100 units/kg IV bolus, then 12-18 units/kg/hr IV; or, 5000 units SC q8-12h Divided in 2-3 doses Fosinopril sodium Furosemide Torsemide Enoxaparin OR Daltaparin OR 10- 80 mg 20-320 mg 5-20 mg 1 mg/kg bid or 1.5 mg/kg SC daily; 5000-10,000 IU SC daily or q12h 175 IU/kg SC daily 40-200 mg 12.5- 50 mg 8 mcg 58. 59. 60. Hydralazine HCl Hydrochlorothaizide Ipratropium 40-200 mg 12.5- 50 mg 17 mcg/inhalation Divided in 2-4 doses In 1 dose 2 inhalations qid PRN Tinzaparin Hydralazine HCl Hydrochlorothaizide Tiotropium 61. 62. 63. Indapamide Irbesartan Isosorbide Dinitrate 1.25- 5 mg 150- 300 mg 10- 240 mg (at least 8 hour washout period to avoid Nitrate Tolerance) In 1 dose In 1 dose Divided in 3 doses Indapamide Irbesartan Isosorbide Dinitrate SR 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. Isradipine Itraconazole Ketoconazole Labetalol HCl Lacosamide Lamotrigine Lanzoprazole Levetiracetam Levofloxacin Lisinopril Loratadine Losartan potassium Mebendazole Meloxicam Methyldopa Metolazone Metopralol Succinate SR 5-20mg 400 mg 200- 400 mg 200- 1200 mg 200-400 mg 100-500 mg 15- 30 mg 1000-3000 mg 500 mg 5- 40 mg 10 mg 25- 100 mg 100 mg 7.5-15 mg 250- 2000 mg 1.25-5 mg 50- 400 mg Divided in 2 doses Divided in 2 doses In 1 dose Divided in 2 doses Divided in 2 doses Divided in 2 doses In 1 dose Divided in 2 doses In 1 dose In 1 dose In 1 dose Divided in 1-2 doses 2 times In 1 dose In 2 divided doses in 1 dose Divided in 1-2 doses Isradipine SR Itraconazole Ketoconazole Labetalol HCl Lacosamide Lamotrigine Lanzoprazole Levetiracetam Levofloxacin Lisinopril Loratadine Losartan potassium Mebendazole Meloxicam methyldopa Metolazone Metopralol sccinate SR 1.25- 5 mg 150- 300 mg 20-120 mg (at least 8 hour washout period to avoid Nitrate Tolerance) 5-20 mg 400 mg 200- 400 mg 200- 1200 mg 200-400 mg 100-500 mg 15- 30 mg 1000-3000 mg 500 mg 5- 40 mg 10 mg 25- 100 mg 100 mg 7.5-15 mg 250-2000mg 1.25-5 mg 50- 400 mg 81. Metoprolol Tartrate 50-200 mg Divided in 1-2 doses Metoprolol 50-300 mg Divided in 1-2 doses Divided in 2 doses In 1 or 2 doses In 1-2 doses In 1-2 doses In 1 dose Divided in 2 doses In 1 dose In 1 dose In 1 dose In 1 dose Divided in 2-3 doses In 1 dose Divided in 2 doses In 1 dose Divided in 2 doses Divided in 2 doses Divided in 2 doses In 1 dose Divided in 2 doses In 1 dose In 1 dose In 1 dose Divided in 1-2 doses 2 times In 1 dose In 2 divided doses in 1 dose Divided in 1-2 doses Divided in 1-2 doses 82. 83. 84. 85. 86. 87. Minocycline Minoxidil Montelukast Moxifloxacin Nadolol Nalidixic Acid 50-100 mg 2,5-40 mg 10 mg 400 mg 20-320 mg 500-1000 mg 1-2 times Divided in 1-2 doses In 1 dose In 1 dose In 1 dose 4 times Minocycline Minoxidil Montelukast Moxifloxacin Nadolol Norfloxacin Ciprofloxacin Divided in 2-3 doses Pindolol Piroxicam Posaconazole Pravastatin Doxazocin Mesylate Terazosin HCl Pregabalin 50-100 mg 10-40 mg 10 mg 400 mg 20-320 mg 400-800 mg 250750mg 500-1000mg 5-40 mg 20-120 mg 30-90 mg 30-90 mg 20-120 mg 400 mg 400 mg 400 mg 20-40 mg 10-20 mg 20-40 mg 900-2400 mg 6-12 mg 20-40 mg 10-20 mg 90-150 mg 300-400 mg (Blood Level 10-20 mcg/ml) 10-60 mg 10-20 mg 400 mg 20-40 mg 1-16 mg 1-20 mg 150-600 mg 88. 89. 90. Naproxen Nebivolol Nifedipine SR 500-1000mg 5-40 mg 20-120 mg Divided in 1-2 doses In 1 dose Divided in 1-2 doses 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. Nifedipine SR Nifedipine Nitrofurantoin Norfloxacin Ofloxacin Olmesartan Olanzapine Omeprazole Oxcarbazepine Paliperidone Pantoprazole Paroxetine Phenobarbital Pheynetion In 1 dose Divided in 3 doses 4 times 2 times 2 times In 1 dose In 1 dose Divided in 1-2 doses Divided in 2 doses In 1 dose In 1 dose In 1 dose In 2-3 dose Divided in 1-3 doses 105. 106. 107. 108. 109. Pindolol Piroxicam Posaconazole Pravastatin Prazosin HCl 30-90 mg 10-120 mg 50-100 mg 400 mg 400 mg 20-40 mg 10-20 mg 20-40 mg 900-2400 mg 6-12 mg 20-40 mg 10-20 mg 90-150 mg 300-400 mg (Blood Level 10-20 mcg/ml) 10-60 mg 10-20 mg 400 mg 20-40 mg 1-20 mg Naproxen Nebivolol Nifedipine SR Nifedipine SR Nifedipine SR Nifedipine SR Norfloxacin Norfloxacin Ofloxacin Olmesartan Olanzapine Omeprazole Oxcarbazepine Paliperidone Pantoprazole Paroxetine Phenobarbital Pheynetion Divided in 2 doses In 1 dose 2 times In 1 dose Divided in 2-3 doses 110. Pregabalin 150-600 mg 111. Perindopril 112. 113. Propranolol HCl Quinapril HCl 1-2 times Divided in 1-2 doses In 1 dose In 1 dose In 1 dose 2 times 2 times Divided in 1-2 doses In 1 dose Divided in 1-2 doses In 1 dose In 1 dose Divided in 1-2 doses 2 times 2 times 2 times In 1 dose In 1 dose Divided in 1-2 doses Divided in 2 doses In 1 dose In 1 dose In 1 dose In 2 dose In 1 dose Divided in 2 doses In 1 dose 2 times In 1 dose In 1 dose In 1 dose Divided in 2 doses 4-8 mg In 1-2 doses Perindopril 4-8 mg In 1-2 doses 40-480 mg 5-80 mg Divided in 2-3 doses Divided in 1-2 doses Propranolol HCl (LA) Quinapril HCl 40-480 mg 5-80 mg In 1 dose Divided in 1-2 114. 115. Ramipril Ranitidine In 1-2 doses 2 times In 1 dose In 1 dose Ramipril Ranitidine 1.25-20 mg 300 mg In 1-2 doses In 1 dose Rabeprazole 1.25-20 mg 150 mg 300 mg 20 mg 116. Rabeprazole 20 mg In 1 dose 117. Risperidone 4-8 mg In 1 dose Risperidone 4-8 mg In 1 dose 118. Salmetrol 21 Mcg/puff 2 puff 2 times Salmetrol 21 Mcg/puff 2 puff 2 times 119. 120. 121. Sertraline Simvastatin Sparfloxacin 25-100 mg 20-40 mg 400 mg loading then 200 mg In 1 dose In 1 dose In 1 dose Sertraline Simvastatin Sparfloxacin 25-100 mg 20-40 mg 400 mg loading then 200 mg In 1 dose In 1 dose In 1 dose 122. 123. 124. 125. 126. Spironolactone Sulindac Telmisartan Terazosin HCl Terbinafine 12.5-100 mg 200-400 mg 40-80 mg 1-20 mg 250 mg Divided in 1-2 doses Divided in 2 doses In 1 dose In 1 dose In 1 dose Spironolactone Sulindac Termisartan Terazosin HCl Terbinafine 12.5-100 mg 200-400 mg 40-80 mg 1-20 mg 250 mg Divided in 2 doses Divided in 2 doses In 1 dose In 1 dose In 1 dose 127. Theophylline Plain Depend on the salt (Blood Level 10-20) mcg/ml) Divided in 3 doses Theophylline SR Depend on the salt (Blood Level 5-15) mcg/ml) Divided in 2 doses 128. 129. 130. 131. 132. 133. 134. 135. Telmisartan Tinzaparin Topiramate Torsemide Triameterene Trovafloxacin Trifluoperazine Valporic Acid In 1 dose In 1 dose Divided in 2 doses Divided in 1-2 doses In 1-2 diveded dose In 1 dose 2 times Divided in 2-3 doses Telmisartan Tinzaparin Topiramate Torsemide Triameterene Trovafloxacin Trifluoperazine Valporic Acid Valsartan Verpamil HCl Vigabatran Voriconazol Zonisamide In 1 dose Divided in 3 doses Divided in 2 doses Divided in 2 doses In 1-2 dose Valsartan Verpamil HCl (SR) Vigabatran Voriconazol Zonisamide 40-80 mg 175 IU/kg SC daily 200-400 mg 5-20 mg 50-150 mg 200 mg 2-10 mg 1000-3000 mg (Blood Level 40100 mcg/ml) 80-320 mg 90-480 mg 3 GM 400 mg 100-400 mg In 1 dose In 1 dose Divided in 2 doses Divided in 1-2 doses In 1-2 diveded dose In 1 dose 2 times Divided in 2 doses 136. 137. 138. 139. 140. 40-80 mg 175 IU/kg SC daily 200-400 mg 5-20 mg 50-150 mg 200 mg 2-10 mg 1000-3000 mg (Blood Level 40-100 mcg/ml) 80-320 mg 40-480 mg 3 GM 400 mg 100-600 mg In 1 dose Divided in 1-2 doses Divided in 2 doses Divided in 2 doses In 1-2 dose Table 3 Drug therapy Registration and MOH Formulaary Status No 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. Drug Status Acebutolol Aliskiren Amiloride HCl Amitriptyline Amlodepine besylate Amoxicillin Aspirin Atenolol Atorvastatine Aripiprazol Betoxalol Bisoprolol Candesartan Captopril Carbamazepine Carteolol Carvedilol Cefacolr Celeoxib Cephalexin Cerivastatin Chlorthalidone Cholestyramine Cimitidine Ciprofloxacin Citalopram Clobazam Clonazepan Clopidogrel Clonidine Cloxacillin Cotrimoxazole Dalteparin RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF Drug 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 101. 102. Levetiracetam Levofloxacin Lisinopril Loratadine Losartan potassium Mebendazole Meloxicam Methyldopa Metolazone Metopralol Succinate SR Metoprolol Tartrate Minocycline Minoxidil Montelukast Moxifloxacin Nadolol Nalidixic Acid Naproxen Nebivolol Nifedipine 20mg SR Nifedipine 30mg SR Nifedipine 10 mg Nitrofurantoin Norfloxacin Ofloxacin Olmesartan Olanzapine Omeprazole Oxcarbazepine Paliperidone Pantoprazole Paroxetine Phenobarbital Status RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , RSFDA , MOHDF RSFDA RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. Diclofenac Diflunisal Digoxin Diltiazem HCl Doxazocin Mesylate Doxycyline Duloxetine Eplerenone Eprosartan Enalpril maleate Enoxaparin Erythromycin Ethosuximide Escitalopram Esomeprazole Felodipine Flucloxacillin Fluconazole Fluoxetine Folic acid Famotidine Fosinopril sodium Furosemide Unfractionated Heparin Hydralazine HCl Hydrochlorothaizide Ipratropium Indapamide Irbesartan Isosorbide Dinitrate Isradipine Itraconazole Ketoconazole Labetalol HCl Lacosamide Lamotrigine Lanzoprazole RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA RSFDA , MOHDF RSFDA , MOHDF 103. 104. 105. 106. 107. 108. 109. 110. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. Pheynetion Pindolol Piroxicam Posaconazole Pravastatin Prazosin HCl Pregabalin Perindopril Propranolol HCl Quinapril HCl Ramipril Ranitidine Rabeprazole Risperidone Salmetrol 21 Mcg/puff Simvastatin Sertraline Sparfloxacin Spironolactone Sulindac Telmisartan Terazosin HCl Terbinafine Theophylline Plain RSFDA , MOHDF RSFDA RSFDA RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140. Telmisartan Tinzaparin Topiramate Torsemide Triameterene Trifluoperazine Trovafloxacin Valporic Acid Valsartan Verpamil HCl Vigabatran Voriconazol Zonisamide RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA , MOHDF RSFDA RSFDA: The Drug had been registered in Saudi Food and Drug Authority MOHDF : The Drug is Ministery of Health Drug Formulary