Sample Medication Use Guidelines

The chart below lists nonformulary medications and their formulary equivalents. The doses listed are representative equivalent doses and should be used to calculate other equivalent doses. For example, benazepril 20 mg should be changed to ramipril 5 mg.

Example Formulary Equivalents Chart





Alpha-1 Adrenergic Blockers

Terazosin (Hytrin) 1 mg, 2mg, 5 mg, 10 mg

Doxazosin (Cardura) 1 mg, 2 mg, 4 mg, 8 mg

Angiotensin Converting Enzyme Inhibitors

Benazepril (Lotensin) 10 mg

Ramipril (Altace) 2.5 mg

Enalapril (Vasotec) 5 mg

Ramipril (Altace) 2.5 mg

Fosinopril (Monopril) 10 mg

Ramipril (Altace) 2.5 mg

Lisinopril (Prinivil, Zestril) 10 mg

Ramipril (Altace) 2.5 mg

Moexipril (Univasc) 7.5 mg

Ramipril (Altace) 2.5 mg

Quinapril (Accupril) 10 mg

Ramipril (Altace) 2.5 mg

Trandolapril (Mavik) 1 mg

Ramipril (Altace) 2.5 mg

Angiotensin Receptor Antagonists

Candesartin (Atacand) 8 mg

Losartan (Cozaar) 25 mg

Irbesartan (Avapro) 75 mg

Losartan (Cozaar) 25 mg

Telmisartan (Micardis) 40 mg

Losartan (Cozaar) 25 mg

Valsartan (Diovan) 80 mg

Losartan (Cozaar) 25 mg


Fexofenadine (Allegra) 60 mg bid

Loratidine (Claritin) 10 mg qd

Loratidine (Claritin) 10 mg qd

Fexofenadine (Allegra) 60 mg bid


Chlordiazepoxide (Librium) 100 mg injection

Diazepam 10 mg injection

Flurazepam (Dalmane) 15 mg

Temazepam (Restoril) 15 mg

Oxazepam (Serax) 30 mg

Lorazepam (Ativan) 2 mg

Beta Adrenergic Blocking Agents

Betaxolol 10 mg/day

Atenolol 50 mg/day

Bisoprolol 5 mg/day

Atenolol 50 mg/day

Metoprolol 100 mg/day

Atenolol 50 mg/day

Nadolol 40 mg/day

Atenolol 50 mg/day or Propranolol 40 mg bid

Timolol 20 mg/day (10 mg bid)

Atenolol 50 mg/day or Propranolol 40 mg bid

Calcium Channel Blockers

Diltiazem (Dilacor XR, Diltia XT, Tiamate, Tiazac) 120 mg

Diltiazem (Diltiazem CD) 120 mg

Isradipine 2.5 mg bid

Felodipine 5 mg/day

Nicardipine 10 mg tid or 30 mg SR bid

Felodipine 5 mg/day

Nifedipine (Adalat CC) 30 mg

Nifedipine (Procardia XL) 30 mg

Nisoldipine 20 mg/day

Felodipine 5 mg/day

Verapamil (Verelan, Covera-HS) 120 mg

Verapamil SR 120 mg



Bumetanide (Bumex) 1 mg

Furosemide (Lasix) 40 mg

Histamine-2 Receptor Antagonists


Cimetidine (Tagamet) 400 mg bid

Nizatidine 150 mg bid

Famotidine (Pepcid) 20 mg bid

Nizatidine 150 mg bid

Ranitidine (Zantac) 150 mg bid

Nizatidine 150 mg bid



Example Summary of Restricted Drugs Listed by Services Responsible for Approval

*Pharmacists may approve for certain indications



Adult & Pediatric Infectious Diseases

Abciximab (cath lab only)

Anti-Hemophilic Factor, Porcine



Anit-Inhibitor Complex



Anit-Thrombin III



Factor VIIa







Fluconazole (IV and PO)*


ICU’s only




Itraconazole (PO)*



Meropenem for CF only

All chemotherapy



Epoetin alfa (off label use)



Ondansetron PO



Ondansetron IV

Mechlorethamine Ointment




Vancomycin (PO)*









Pilocarpine Inserts




Example List of Restricted Medications




Restricted to use in the Cardiac Catherization lab.


Pediatric orders must be approved by the Pediatric Infectious Diseases Service. Adult use is not restricted.

Pharmacists may approve for:

1. Documented Herpes simplex (HSV-1, HSV-2) and varicella zoster infections.


All orders must be approved by the Adult or Pediatric Infectious Diseases Service.

Pharmacists may approve use for:

  1. Serious Gram-negative infections resistant to gentamicin and tobramycin
  2. Patients in the Burn Unit
  3. Progressive sepsis in a patient already receiving gentamicin or tobramycin


All orders must be approved by the Cardiology Service.

Amphotericin B Lipid Complex (ABLC)

All orders must be approved by the Adult or Pediatric Infectious Diseases Service.

Pharmacists may approve use if meets guidelines. Guidelines for use are as follows:

The main advantage of liposomal amphotericin products is their reduced nephrotoxicity. Reserve use for situations where one of the following conditions are present:

  1. Patient has significant renal impairment at baseline (Scr > 2.0 mg/dL)
  2. Pediatric patient develops a minimum of a 50% increase in SCr from baseline on conventional ampho B
  3. Adult patient develops a minimum of a 100% increase (doubling) in SCr from baseline or reaches a SCr of 1.8 mg/dL, whichever comes first
  4. If a patient fails to improve on conventional amphotericin, the ID consult service should be consulted for a recommendation about whether to switch to a lipid product
  5. Switching from conventional amphotericin B to a liposomal amphotericin product due to infusion reactions with ampho B is not recommended; there is no evidence that the infusion reactions will be lessened with the use of a lipid product
  6. Abelcet is the lipid amphotericin product of choice at <>. Ambisome will not be ordered nonformulary (designated nonformulary, not available) unless it is as a free drug as part of a study protocol.

Anti-Hemophilic Factor, Porcine

All orders must be approved by the Coagulation Service.

Anti-Inhibitor Complex

All orders must be approved by the Coagulation Service.

Anti-Thrombin III

All orders must be approved by the Coagulation Service (Pediatric Liver Transplant exempt)


Available for use at 80 mg/day dosage only. Otherwise, substitute simvastatin per Formulary Equivalents Policy


All orders must be approved by the Adult or Pediatric Infectious Diseases Service.

Pharmacists may approve use for:

1. Infections caused by Gram-negative rods in patients allergic to penicillin with a history of anaphylactic reactions or allergy to a cephalosporin

Butorphanol (Stadol)

Restricted to use in the OR.



Example Medication Hypertext Index

  1. Abciximab – Restricted Drug
  2. Acyclovir – Restricted Drug
  3. Amikacin – Restricted Drug
  4. Amiodarone- Restricted Drug
  5. Amphotericin B Lipid Complex (ABLC) – Restricted Drug
  6. Anti-Hemophilic Factor, Porcine – Restricted Drug
  7. Anti-Inhibitor Complex – Restricted Drug
  8. Anti-Thrombin III – Restricted Drug
  9. Atorvastatin – Restricted Drug
  10. Aztreonam – Restricted Drug
  11. Benazepril – Therapeutic Substitution Drug
  12. Betaxolol – Therapeutic Substitution Drug
  13. Bisoprolol - Therapeutic Substitution Drug
  14. Bumetanide – Therapeutic Substitution Drug
  15. Butorphanol – Restricted Drug
  16. Candesartan - Therapeutic Substitution Drug
  17. Chlordiazepoxide – Therapeutic Substitution Drug
  18. Cimetidine – Therapeutic Substitution Drug
  19. Diltiazem – Therapeutic Substitution Drug
  20. Enalapril - Therapeutic Substitution Drug
  21. Famotidine – Therapeutic Substitution Drug
  22. Flurazepam – Therapeutic Substitution Drug
  23. Fosinopril - Therapeutic Substitution Drug
  24. Irbesartan - Therapeutic Substitution Drug
  25. Isradipine – Therapeutic Substitution Drug
  26. Lisinopril - Therapeutic Substitution Drug
  27. Loratidine - Therapeutic Substitution Drug
  28. Metoprolol - Therapeutic Substitution Drug
  29. Moexipril - Therapeutic Substitution Drug
  30. Nadolol - Therapeutic Substitution Drug
  31. Nicardipine – Therapeutic Substitution Drug
  32. Nifedipine – Therapeutic Substitution Drug
  33. Nisoldipine – Therapeutic Substitution Drug
  34. Oxazepam – Therapeutic Substitution Drug
  35. Quinapril - Therapeutic Substitution Drug
  36. Ranitidine – Therapeutic Substitution Drug
  37. Telmisartan - Therapeutic Substitution Drug
  38. Terazosin - Therapeutic Substitution Drug
  39. Timolol - Therapeutic Substitution Drug
  40. Trandolapril - Therapeutic Substitution Drug
  41. Valsartan - Therapeutic Substitution Drug
  42. Verapamil – Therapeutic Substitution Drug