Calgary LTC Formulary - Medication Listing
Revised June 1, 2016
CALGARY ZONE
Medication Listing
Calgary Zone Long Term Care Formulary
Preamble:
The LTC Formulary identifies funded drug therapy for Continuing Care. Medications listed in the Formulary and utilized according to Formulary guidelines will receive full funding. Additional funding
is available for medications not listed on Formulary or not used in accordance with Formulary guidelines,.through the Non-Formulary (NF) process and approval by AHS, where a rational case to
support use has been presented to the AHS Supported Living Pharmacists and LTC Pharmacy and Therapeutics (P&T) Committee.
The formulary is regularly reviewed and updated as consensus from the P&T committee. Stakeholders are encouraged to provide comment and suggestions to facilitate the ongoing development
of the Formulary. o
On Low-Cost Alternative (LCA) Products1:
Whenever possible, it is expected that the LCA product be dispensed. Typically, these will be generic medicines or an alternative brand name to the original manufactured product. Similarly,
clients will be expected to use the LCA dosage forms whenever possible and as clinically appropriate (e.g. regular tablets instead of quick-dissolve tablets, or oral solids instead of liquids)
1Exemptions to this will only be granted via the non-formulary process on an individual client basis, or in the event of a supply issue, at the discretion of ISFL Clinical Pharmacists.
Compounds and Alternate Dosing Forms (see FPP-10 for greater detail):
Only compounds for topical use are considered regular formulary items. For compound eligibility, all active ingredients must be listed as a benefit on the LTC formulary list, and must be listed for
topical use (e.g. gabapentin PO does not grant eligibility for gabapentin topical coverage).
Compounds of commerically available items for altered routes of administration (e.g. compounded omeprazole suspension, or compounded capsules of a medication without a potential allergen)
are considered non-formulary and must be approved for coverage via the NF process.
Grace Period (see FPP-04 for greater detail):
Whenever possible, it is expected that medication regimens be compliant to formulary listings, restrictions, and autosubstitutions, but it is recognized that medication changes to comply with the
Formulary at the time of admission are not always appropriate and that time is necessary to collect appropriate information and make assessments regarding need. To facilitate those admissions
and to promote rational prescribing, the committee has built in a "grace period" of up to 3 weeks where possible to allow for medication use that is not in accordance with Formulary guidelines.
This grace period applies to all medications, including those medications usually considered for autosubstitutions. In situations where a 3 week period is insufficient to allow for drug changes, the
“grace period” may be extended up to the initial care conference or initial quarterly medication review, up to a period of 6 weeks. This will allow for funded drug use of medications not listed in the
Formulary and/or use “outside” Formulary guidelines for new admissions from Acute Care or the community unless otherwise specified in the Formulary.
© 2015 Alberta Health Services. This material is provided on an "as is", "where is" basis. Alberta Health Services does not make any representation or warranty, express, implied or
statutory, as to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information. This material is not a substitute for the advice of a qualified health
professional. Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use.
AHFS Class Generic Name
4:00 ANTIHISTAMINE DRUGS
4:04 First Generation Antihistamines
cyproheptadine
diphenhydramine
diphenhydramine
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
Health Canada Advisories - Search Page
Periactin
Benadryl
Benadryl
4 mg tab, 2 mg/5mL liquid
25, 50 mg cap, 12.5 mg/5 mL liquid
50 mg/mL
Oral
oral
Injection
4:08 Second Generation Antihistamines
1
Calgary LTC Formulary - Medication Listing
Revised June 1, 2016
AHFS Class Generic Name
cetirizine
loratadine
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Reactine
10 mg, 20 mg tabs
Claritin
10 mg tab
Route of
Adminstration
oral
oral
8:00 ANTI-INFECTIVES
8:12.02 Aminoglycosides
gentamicin
tobramycin
Garamycin
Nebcin
40 mg/mL
40 mg/mL
injection
injection
8:12.06 Cephalosporins
cefazolin
cephalexin
cefaclor
cefixime
cefuroxime axetil
ceftriaxone
Ancel
Keflex
Ceclor
Suprax
Ceftin
Rocephin
500 mg/10mL, 1 g/10mL
250 mg & 500 mg tabs, 250 mg/5mL liquid
non-formulary (autosub to cefuroxime)
400 mg tab, 100 mg/5mL liquid
250 mg, 500 mg tab
0.25 g, 1 g & 2 g
injection
oral
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
ASL-01
oral
oral
injection
RS-06
8:12.12 Macrolides
azithromycin
Zithromax
clarithromycin
erythromycin base
erythromycin EC
erythromycin salts
erythromycin estolate
8:12.16 Penicillins
amoxicillin
amoxicillin/clavuanate
ampillicin
ampillicin
cloxacillin
cloxacillin
penicillin G sodium
penicillin V potassium
oral
RS-30
Biaxin
E-mycin
Eryc
LCA
LCA
250 mg, 500 mg & 600 mg cap
250 mg, 500 mg tabs (autosub to azithromycin unless
meets RS-30)
250 mg
250 mg, 333 mg cap
non-formulary (autosub to erythromycin base)
50 mg/mL liquid
oral
oral
oral
ASL-01
Amoxil
250 mg & 500 mg caps, 250 mg/5mL liquid
oral
Clavulin
LCA
LCA
LCA
LCA
LCA
LCA
250mg*125mg, 500mg*125mg, 875*125mg tabs,
250mg*125 mg/5mL, 500mg*125 mg/5mL liquids
non-formulary (oral forms auto to amoxicillin)
500 mg/vial
250 mg & 500 mg caps, 125 mg/5mL liquid
500 mg, 1 g vials
1 million units/vial, 10 million units/vial
300 mg (500,000 units) tab, 125 mg/mL liquid
oral
oral
injection
oral
injection
injection
oral
Cipro
Levaquin
Noroxin
250 mg, 500 mg tabs
250 mg, 500 mg tabs
400 mg tab
oral
oral
oral
Salozopyrin, SSZ
500 mg tab, 500 mg EC tab
oral
Health Canada Advisory (May 2013) - Rare
reports of potential QT prolongation at regular
therapeutic doses
RS-30
ASL-01
oral
ASL-01
8:12.18 Quinolones
ciprofloxacin
levofloxacin
norfloxacin
8:12.20 Sulfonamides
sulfasalazine
RS-02
RS-02
RS-02
2
Calgary LTC Formulary - Medication Listing
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
AHFS Class Generic Name
available)1
Strength
sulfamethoxazole/trimeth
400mg*80mg, 800mg*160mg tabs, 40mg*8mg/mL
oprim
Bactrim, Septra
liquid
Route of
Adminstration
Relevant
Formulary
Links
oral
8:12.24 Tetracyclines
doxycycline
tetracycline
Vibramycin
LCA
100 mg tab/cap
250 mg, 125 mg/5mL liquid
oral
oral
8:12.28 Miscellaneous
clindamycin
clindamycin
vancomycin
vancomycin
Dalacin C
Dalacin C
Vanocin
Vanocin
150 mg & 300 mg caps, 75 mg/5mL
150 mg/mL
125 mg, 250 mg cap
500 mg/vial
oral
injection
oral
injection
8:14 Antifungals
fluconazole
nystatin
Diflucan
Nilstat, Mycostatin
50 mg, 100 mg, & 150 mg tab
100,000 units/mL liquid
oral
oral
RS-23
Lamisil
250 mg tab
oral
HCD-26
isoniazid
Isotamine
100 mg
oral
LTC Exemption
rifampin
Rifadin
150 mg, 300 mg cap
oral
LTC Exemption
8:18 Antivirals
acyclovir
Zovirax
non-formulary autosub to valacyclovir
Symmetrel
Famvir
Tamiflu
Valtrex
100 mg cap, 10 mg/mL liquid
non-formulary, autosub to valacyclovir
30 mg & 75 mg capsules, 6 mg/mL liquid
500 mg tab
oral
8:30 Antiprotozoals
hydroxychloroquine
quinine sulfate
metronidazole
Plaquenil
LCA
Flagyl
200 mg tab
200 mg & 300 mg caps
250 mg tab
oral
oral
oral
8:36 Urinary Anti-infectives
fosfomycin
Monurol
3 g satchet
oral
HCD-24
500 mg tab
50 mg & 100 mg tablets
oral
oral
ASL-01
terbinafine
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
HCD-22
For oral compounding use for C-difficile
infection under HCD-22 criteria. All
HCD-22
RS-17
RS-23
HCD for treatment of onychomycosis
only if affecting functioning or pain
8:16 Antimycobacterials
amantadine
famciclovir
oseltamivir
valacyclovir
methanamine mandelate Mandelamine
nitrofurantoin
AA Pharma
For TB treatment or prophylaxis, see
attachment . All other use is consered
non-formulary
ASL-01
topical use is also non-formulary
HCD-03
see 28.36 for use in movement disorders
ASL-01
oral
oral
HCD-03
ASL-01
preferred formulary antiviral agent
3
Calgary LTC Formulary - Medication Listing
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
Teva-Nitrofurantoin
50 mg & 100 mg capsules
oral
MacroBID
Proloprim
100 mg capsule
100 mg tab
oral
oral
ASL-01
methotrexate
LCA
2.5 mg tab
oral
RS-41
methotrexate
LCA
10mg/mL & 25 mg/mL injection, 10 mg/mL, 15 mg/1.5
mL, 20 mg/2mL 25mg/2.5 mL prefilled syringes
injection
AHFS Class Generic Name
nitrofurantoin
macrocrystals
nitrofurantoin
macrocrystals/
monohydrate
trimethoprim
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
temporarily listed during shortage
RS-32
temporarily listed during shortage
10:00 ANTINEOPLASTICS
Metoject Prefilled syringes have
additional restrictions
RS-41
12:00 CHOLINERGIC DRUGS
12:04.00 Parasympathomemetic (Cholinergic) Agents
bethanechol chloride
Duvoid, Urecholine
donepezil
Aricept
galantamine ER
Reminyl
pyridostigmine
Mestinon
10 mg & 25 mg tabs
5 mg & 10 mg tabs, 1 mg/mL liquid
8 mg, 16 mg & 24 mg caps
60 mg tab, 180mg SR tab
oral
oral
oral
oral
HCD-09
HCD-09
rivastigmine
Exelon
1.5 mg, 3 mg, 4.5 mg & 6mg caps, 2 mg/mL liquid
oral
HCD-09
rivastigmine
Exelon
4.6mg/24 hour, 9.6mg/24 hour patch
topical
HCD-09
0.4 mg/mL, 0.6 mg/mL
injection
oral
oral
inhaled (oral)
inhaled (nasal)
RS-21
RS-21
12:08.08 Antimuscarinic/Antispasmodic Agents
atropine sulfate
LCA
belladonna / ergotamine
tartrate / phenobarbital
dicyclomine
Bellergal Spacetabs
Bentylol
ipratropium bromide
ipratropium bromide
Atrovent
Atrovent
0.2mg*0.6mg*40mg tab
10 mg tab
20 mcg/dose MDI, 125 mcg/mL & 250 mcg/mL inh
solution (nebules)
0.03% nasal spray
ipratropium bromide /
salbutamol sulfate
scopolamine
hydrobromide
scopolamine
hydrobromide
tiotropium bromide
Combivent, Teva-Combo
Sterinebs
0.2mg/mL*1mg/mL inh solution (nebules)
inhaled (oral)
Transderm-V
1.5 mg patch
transdermal
LCA
Spiriva
0.4 mg/mL
18 mcg caps
injection
inhaled (oral)
restricted to client with documented
intolerance with oral product
ASL-01
use of nebulizers restricted
ASL-01
should be autosubbed to individual
ingredients via MDI wherever possible
RS-38
12:12 Sympathomimetic (Adrenergic) Agents
4
Calgary LTC Formulary - Medication Listing
AHFS Class Generic Name
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
budesonide / formoterol
epinephrine
formoterol
midodrine
pseudoephedine
Symbicort
Adrenalin
Foradil, Oxeze
LCA
Sudafed
salbutamol
Ventolin
salmeterol
Serevent
salmeterol / fluticasone
Advair
Symbicort 100 (100mcg/dose*6mcg/dose), Symbicort
200 (200mcg/dose*6mcg/dose) Turbuhalers
1 mg/mL
6 mcg/dose & 12 mcg/dose
2.5 mg & 5 mg tabs
30 mg & 60 mg tabs
100 mcg MDI, 0.5 mg/mL, 1 mg/mL, 2 mg/mL &
5mg/mL inh solution (nebules)
Route of
Adminstration
inhaled (oral)
injection
inhaled (oral)
oral
oral
RS-29
inhaled (oral)
RS-21
25 mg MDI, 50 mg diskus
inhaled (oral)
Advair 100 Diskus (50mcg/dose*100 mcg/dose),
Advair 250 Diskus (50mcg/dose*250mcg/dose), Advair
500 Diskus (50mcg/dose*500mcg/dose), Advair 125
(25mcg/dose*125mcg/dose), Advair 250
(25mcg/dose*250mcg/dose) MDI
inhaled (oral)
RS-29
12:16.04 Selective α1-Adrenergic Blocking Agents
tamsulosin
Flomax
0.4 mg cap, 0.4 mg SR tab
oral
12:20 Skeletal Muscle Relaxant
baclofen
cyclobenzaprine
dantrolene sodium
Lioresal
Flexeril
Dantrium
10 mg & 20 mg tabs
10 mg tab
25 mg & 100 mg caps
oral
oral
oral
Robaxin
500 mg tab
oral
methocarbamol
tizanidine
Relevant
Formulary
Links
Zanaflex
4 mg tab
oral
RS-36
nicotine gum/lozenge
Nicorette
1 mg, 2 mg & 4 mg varieties
oral
RS-26
nicotine patch
Nicoderm
7 mg/hr, 14 mg/hr & 21 mg/hr varieties
transdermal
RS-26
75 mg tab
oral
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
ASL-01
Approved for use for the management
of spasticity, when consultation with a
neurologist or physiatrist results in
recommendations for use.
12:92 Miscellaneous Autonomic Drugs
20:00 BLOOD FORMATION AND COAGULATION
clopidogrel
Plavix
Maximum duration of therapy: 12 weeks
(see RS-26 for detail)
Maximum duration of therapy: 12 weeks
(see RS-26 for detail)
5
Calgary LTC Formulary - Medication Listing
Revised June 1, 2016
epoetin alpha
enoxaparin
ferrous fumarate
ferrous gluconate
ferrous sulfate
heme iron polypeptide
heparin sodium
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
2500 unit/syr, 5000 unit/syr, 7500 unit/syr, 10 000
unit/syr, 12 500 unit/syr, 15 000 unit/syr & 18 000
unit/syr syringes, 10 000 unit/mL & 25 000 unit/mL
Fragmin
vials
10 mcg/syr, 20 mcg/syr, 30 mcg/syr, 40 mcg/syr, 50
mcg/syr, 60 mcg/syr, 80 mcg/syr, 100 mcg/syr, 130
mcg/syr, 150 mcg/syr, 200 mcg/syr, 300 mcg/syr &
Aranesp
500 mcg/syr syringes
1000 unit/syr, 2000 unit/syr, 3000 unit/syr, 4000
unit/syr, 5000 unit/syr, 6000 unit/syr, 8000 unit/syr,
10 000 unit/syr, 20 000 unit/syr, 30 000 unit/syr & 40
Eprex
000 unit/syr syringes
Lovenox
100 mg/mL
Palafer
300 mg cap
LCA
300 mg tab
LCA
300 mg tab, 30 mg/mL liquid
Proferrin
non-formulary - autosub to ferrous gluconate
LCA
10 000 unit/mL
pentoxifylline
Trental
AHFS Class Generic Name
dalteparin
darbepoetin alpha
400 mg tab
Route of
Adminstration
Relevant
Formulary
Links
injection
HCD-06
injection
HCD-04
injection
injection
oral
oral
oral
HCD-04
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
HCD-06
ASL-01
injection
oral
HCD-06
Coumadin
10 000 unit/mL
injection
compounded 5% gel (or similar)
topical
1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg &
10 mg tabs
oral
Health Canada Advisory (Oct 2010) - not
recommended in patients > 70 years of age with
renal impairment; use with caution in moderate
to severe renal impairment
amiodarone
Cordarone
200 mg tab
RS-28
Restricted to use (or initiation) by
cardiology or internal medicine
digoxin
Lanoxin
0.0625 mg, 0.125 mg & 0.25 mg tabs, 0.05 mg/mL oral
liquid
oral
disopyramide
Rythmodan
100 mg cap
oral
RS-28
Restricted to use (or initiation) by
cardiology or internal medicine
flecainide
Tambocor
50 mg & 100 mg tabs
oral
RS-28
mexiletine
Mexitil
100 mg & 200 mg caps
oral
RS-28
procainamide
Procan SR
250 mg SR tab
oral
RS-28
propafenone
Rythmol
150 mg tab
oral
RS-28
tinzaparin
tranexamic acid
Innohep
Cyklokapron
warfarin
24.04 Antiarrythmic Agents
oral
Restricted to use (or initiation) by
cardiology or internal medicine
Restricted to use (or initiation) by
cardiology or internal medicine
Restricted to use (or initiation) by
cardiology or internal medicine
Restricted to use (or initiation) by
cardiology or internal medicine
24.06 Antilipemic Agents
6
Calgary LTC Formulary - Medication Listing
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Lipitor
10 mg, 20 mg, 40 mg & 80 mg tabs
Questran
4 gm powder packet
Route of
Adminstration
oral
oral
fenofibrate nanocrystals
Lipidil EZ
non-formulary - autosub to fenofibrate micronized
oral
ASL-01
fenofibrate micronized
Lipidil Micro
67 mg & 200 mg caps
oral
ASL-01
fenofibrate nanocrystals
gemfibrozil
fluvastatin
lovastatin
pravastatin
rosuvastatin
simvastatin
Lipidil Supra
Lopid
Lescol
Mevacor
Pravachol
Crestor
Zocor
non-formulary - autosub to fenofibrate micronized
300 mg & 600 mg tabs
10 mg, 20 mg, 40 mg & 80 mg tabs
10 mg, 20 mg, 40 mg & 80 mg tabs
10 mg, 20 mg & 40 mg tabs
5 mg, 10 mg, 20 mg & 40 mg tabs
5 mg, 10 mg, 20 mg, 40 mg & 80 mg tabs
oral
oral
oral
oral
oral
oral
oral
ASL-01
24.08 Hypotensive Agents
clonidine
hydralazine
Catapres
Apresoline
0.025 mg, 0.1 mg, & 0.2 mg tabs
10 mg, 25 mg & 50 mg tabs
oral
oral
24.12 Vasodilating Agents
dipyridamole / ASA
isosorbide mononitrate
isosorbide dinitrate
Aggrenox
Imdur
Isordil
200mg*25mg cap
60 mg ER tab
10 mg & 30 mg tabs
oral
oral
oral
2% ointment
topical
nitroglycerin
Nitrol
Nitro-Dur LCA (or other
LCA brand if less)
nitroglycerin
Nitrostat/Nitrospray
0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr & 0.8 mg/hr patches transdermal
0.3 mg & 0.6 mg sublingual tabs, 0.4 mg/dose
sublingual spray
oral/sublingual
24.20 α-Adrenergic Blocking Agents
prazosin
terazosin
Minipress
Hytrin
1 mg, 2 mg & 5 mg tabs
1 mg, 2 mg & 5 mg tabs
oral
oral
24:24 β-Adrenergic Blocking Agents
acebutolol
atenolol
bisoprolol
carvedilol
labetalol
metoprolol
nadolol
pindolol
Sectral
Tenormin
Monocor
Coreg
Trandate
Lopresor
Corgard
Visken
oral
oral
oral
oral
oral
oral
oral
oral
oral
AHFS Class Generic Name
atorvastatin
cholestyramine
nitroglycerin
propranolol
Inderal, Inderal LA
100 mg, 200 mg & 400 mg tabs
25 mg, 50 mg & 100 mg tabs
5 mg & 10 mg tabs, 1 mg/mL liquid
3.125 mg, 6.25 mg, 12.5 mg & 25 mg tabs
100 mg & 200 mg tabs
25 mg, 50 mg & 100 mg tabs
40 mg, 80 mg tabs
5 mg, 10 mg tabs
10 mg, 20 mg & 40 mg tabs, 80 mg, 120 mg & 160 mg
LA caps
sotalol
Sotocor
160 mg tab
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
RS-16
preferred formulary fenofibrate product
RS-16
RS-16
RS-16
RS-16
RS-16
oral
RS-28
Restricted to use (or initiation) by
cardiology or internal medicine
7
Calgary LTC Formulary - Medication Listing
AHFS Class Generic Name
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
24.28 Calcium Channel Blocking Agents
amlodipine besylate
Norvasc
diltiazem
Cardizem
diltiazem controlleddelivery capsule
Cardizem CD, Diltiazem CD
diltiazem extendedTiazac, Diltiazem-T,
release capsule
Diltiazem-ER
felodipine
Plendil, Renedil
nifedipine
nifedipine
Adalat
Adalat XL
verapamil
Isoptin, Isoptin SR
Route of
Adminstration
2.5 mg, 5 mg & 10 mg tabs
30 mg & 60 mg tabs (immediate release)
oral
oral
120 mg, 180 mg, 240 mg & 300 mg caps
oral
120 mg, 180 mg, 240 mg, 300 mg & 360 mg caps
2.5 mg, 5 mg & 10 mg tabs
non-formulary (5 mg & 10 mg caps autosub to
captopril)
20 mg, 30 mg & 60 mg XL tabs
80 mg & 120 mg tabs, 120 mg, 180 mg & 240 mg SR
tabs
oral
oral
oral
oral
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
ASL-01
oral
24.32.04 Angiotensin Converting Enzyme Inhibitors/24:32.08 Angiotensin II Receptor Antagonists
ramipril
Altace
1.25 mg, 2.5 mg, 5 mg & 10 mg caps. All ACEI's
autosubstituted to ramipril*
oral
ASL-02
valsartan
captopril
Diovan
Capoten
40 mg, 80 mg, 160 mg & 320 mg tabs. All ARB's
autosubstituted to valsartan*
6.25 mg, 12.5 mg & 25 mg tabs
oral
oral
ASL-02
80 mg chew tabs, 81 mg & 325 mg EC tabs
650 mg supp
oral
rectal
28:00 CENTRAL NERVOUS SYSTEM DRUGS
28:08 Analgesics and Antipyretics
acetylsalicylic acid
Aspirin, ASA
acetylsalicylic acid
Aspirin, ASA
celecoxib
diclofenac
diclofenac
Celebrex
Voltaren, Voltaren SR
Voltaren Emulgel Extra
Strength
*Autosubstitution for indications of
hypertension. For other indications (e.g.
heart failure of any kind), the clinician
will assess each individual case and
either a) follow autosub or b) submit NF
form for alternate choice.
*Autosubstitution for indications of
hypertension. For other indications (e.g.
heart failure of any kind), the clinician
will assess each individual case and
either a) follow autosub or b) submit NF
form for alternate choice.
RS-34
preferred short-acting ACEI
100 mg & 200 mg caps
50 mg tab, 75mg & 100 mg SR tabs
oral
oral
RS-25
2.32% gel
topical
ASL-01
documented intolerance to traditional
NSAIDs in combination with
cytoprotection
RS-11
Voltaren 1.16% gel is non-formulary.
8
Calgary LTC Formulary - Medication Listing
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
diclofenac / misoprostol
ibuprofen
indomethacin
Arthrotec
Advil, Motrin
Indocid
oral
oral
oral
naproxen
naproxen
Naprosyn
Naprosyn
trolamine salicylate,
triethanolamine,
Rub A535 No Odour,
Myoflex, Aspercream, LCA 10% - 20% cream
topical
LCA
oral
AHFS Class Generic Name
28:08 Opiate Agonists
codeine
codeine / acetaminophen/ Tylenol No. 1, Tylenol No.
caffeine
2, Tylenol No. 3
codeine
LCA
50mg*200mg & 75mg*200mg EC tabs
200 mg, 300 mg, 400 mg & 600 mg tabs
25 mg & 50 mg caps
125 mg, 250 mg, 375 mg & 500 mg tabs, 250 mg, 375
mg & 500 mg EC tabs
500 mg supp
15 mg & 30 mg tab, 5 mg/mL liquid
8mg*300mg*15mg tab, 15mg*300mg*15mg tab,
30mg*300mg*15mg tab
30 mg/mL
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr & 100
mcg/hr patch
fentanyl citrate
hydromorphone
hydromorphone
controlled-release
hydromorphone
LCA
Dilaudid
Hydromorph Contin
Dilaudid
50 mcg/mL
1 mg, 2 mg, 4 mg & 8 mg tabs, 1 mg/mL liquid
3 mg, 4.5 mg, 6 mg, 9 mg, 12 mg, 18 mg & 24 mg CR
caps
oral
2 mg/mL
injection
morphine hydrochloride
Ratio-Morphine
1 mg/mL syrup
oral
morphine hydrochloride
sustained-release
M.O.S. SR
30 mg & 60 mg SR tablets
oral
MS.IR, Statex
5 mg, 10 mg, 25 mg & 50 mg Statex tabs, 5 mg, 10
mg, 20 mg and 30 mg MS.IR tabs
oral
transdermal
injection (or for
use SL)
oral
M-Eslon
MS Contin, Teva-Morphine
SR
Statex-Suppositories
LCA
O&B
10 mg, 15mg, 30 mg, 60 mg, 100 mg ER capsules
oral
15 mg, 30 mg, 60 mg, 100 mg SR tablets
5 mg, 10 mg, 20 mg and 30 mg supps
10 mg/mL
65mg*15mg supp
oral
rectal
injection
rectal
Percocet, Endocet
Oxy-IR, Supeudol
5mg*325mg tab
5 mg, 10 mg & 20 mg tab
5 mg, 10 mg , 15 mg, 20 mg, 30 mg, 40 mg, 60 mg &
80 mg CR tabs
20 mg supp
oral
oral
OxyNEO
LCA
Naproxen sodium and naproxen SR are
non-formulary
product must not contain methyl
salicylate
oral
injection
LCA Duragesic-MAT
morphine sulfate
extended-release
morphine sulfate
sustained release
morphine sulfate
morphine sulfate
opium / belladonna
oxycodone/
acetaminophen
oxycodone
oxycodone controlledrelease
oxycodone
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
oral
rectal
fentanyl patch
morphine sulfate
Relevant
Formulary
Links
oral
rectal
HCD-08
FPP-11
Health Canada Advisory (2010, 2009) - not for
use in opioid naive patients
RS-31
for use in incident pain, sublingually
ASL-01
OxyNEO autosubbed to generic CR
brands
9
Calgary LTC Formulary - Medication Listing
AHFS Class Generic Name
28:08.92 Miscellaneous
acetaminophen
acetaminophen
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
Tylenol
Abenol
325 mg & 500 mg tabs, 32 mg/mL & 80 mg/mL liquids oral
650 mg supp
rectal
Narcan
0.4 mg/mL
injection
Revia
50 mg tab
oral
carbamazepine
Tegretol
100 mg & 200 mg tabs, 200 mg & 400 mg CR tabs, 100
mg & 200mg chewable tabs
oral
clobazem
divalproex sodium
gabapentin
lamotrigine
Frisium
Epival
Neurontin
Lamictal
10 mg
125 mg, 250 mg & 500 mg tabs
100 mg, 300 mg & 400 mg caps
25 mg, 100 mg & 150 mg caps
levetiracetam
Keppra
phenobarbital
phenobarbital
primidone
Phenobarb
Phenobarb
Mysoline
28:10 Opiate Antagonists
naloxone
naltrexone
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
HCD-27
for treatment of addictions; requires
psych/addictions follow-up
oral
oral
oral
oral
RS-11
To be used only at recommendation of a
specialist in neurology
250 mg, 500 mg & 750 mg tabs
oral
RS-11
To be used only at recommendation of a
specialist in neurology
15 mg, 30 mg, 60 mg & 100 mg tabs, 5mg/mL liquid
120 mg/mL
125 mg & 250 mg tabs
oral
injection
oral
ASL-01
phenytoin suspension is autosubbed to
tab/cap, or subject to NF approval
process
28:12 Anticonvulsants
phenytoin
topiramate
valproic acid
28:16.04 Antidepressants
amitriptyline
bupropion extended
release
bupropion sustained
release
citalopram
clomipramine
Dilantin
Topamax
Depakene
50 mg tab, 30 mg & 100 mg caps
25 mg, 50 mg, 100 mg & 200 mg tabs
250 mg & 500 mg caps, 50 mg/mL liquid
oral
oral
oral
Elavil
10 mg, 25 mg, 50 mg & 75 mg tabs
oral
Wellbutrin XL
150 mg & 300 mg XL tabs
oral
Wellbutrin SR, Zyban
Celexa
Anafranil
100 mg & 150 mg SR tabs
10 mg, 20 mg & 40 mg tabs
25 mg, 50 mg & 75 mg caps
oral
oral
oral
RS-26
SR tabs are unrestricted when used for
depression. For smoking cessation, the
duration of treatment is restricted to 12
weeks (use 150 mg SR LCA product for
Zyban 150 mg)
Health Canada Advisory (Jan 2012) - Celexa®
(citalopram hydrobromide) should no longer be
prescribed at doses greater than 40 mg per day;
20 mg per day is the maximum recommended
dose for patients who are 65 years of age or who
have other risk factors
10
Calgary LTC Formulary - Medication Listing
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Norpramine
Sinequan
Cymbalta
Cipralex
Prozac
Strength
10 mg, 25 mg, 50 mg & 75 mg tabs
10 mg, 25 mg, 50 mg & 75 mg caps
30 mg & 60 mg caps
10 mg & 20 mg tabs
10 mg & 20 mg caps
Route of
Adminstration
oral
oral
oral
oral
oral
fluvoxamine
Luvox
50 mg & 100 mg tabs
oral
imipramine
Tofranil
10 mg, 25 mg & 75 mg tabs
oral
AHFS Class Generic Name
desipramine
doxepin
duloxetine
escitalopram
fluoxetine
Remeron, Remeron RD
Manerix
Aventyl
Paxil
Zoloft
Desyrel
Surmontil
Effexor XR
15 mg, 30 mg & 45 mg tabs, 15 mg, 30 mg & 45 mg
rapid dissolving tabs
150 mg & 300 mg tabs
10 mg & 25 mg caps
10 mg, 20 mg & 30 mg tabs
25 mg, 50 mg & 100 mg caps
50 mg, 150 mg & 200 mg tabs
12.5 mg, 25 mg & 100 mg tabs
37.5 mg, 75 mg & 150mg XR caps
oral
oral
oral
oral
oral
oral
oral
oral
Abilify Maintena
Abilify
Largactil
Largactil
Clozaril
Fluanxol
Fluanxol Depot
Modecate
300 mg/vial & 400 mg/vial
2 mg, 5 mg, 10 mg, 15 mg, 20 mg & 30 mg tabs
25 mg, 50 mg & 100 mg tabs
25 mg/mL
25 mg & 100 mg tabs
0.5 mg & 3 mg tabs
20 mg/mL & 100 mg/mL
100 mg/mL
injection
oral
oral
injection
oral
oral
injection
injection
haloperidol
haloperidol
loxapine
loxapine
methotrimeprazine
methotrimeprazine
Haldol
Haldol
Loxapac
Loxapac
Nozinan
Nozinan
oral
injection
oral
injection
oral
injection
olanzapine
olanzapine
paliperidone
periciazine
perphenazine
prochlorperazine
prochlorperazine
quetiapine
Zyprexa, Zyprexa Zydis
Zyprexa IM
Invega Sustenna
Neuleptil
Trilafon
Stemetil
Stemetil
Seroquel
0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg tabs, 2mg/mL liquid
5mg/mL
2.5 mg, 5 mg, 10 mg & 25 mg tabs
50 mg/mL
2 mg, 5 mg, 25 mg & 50 mg tabs
25 mg/mL
2.5 mg, 5 mg, 7.5 mg, 10 mg & 15 mg tabs, 5 mg and
10 mg ODT
5 mg/mL
50 mg/syr, 75 mg/syr, 100 mg/syr & 150mg/syr
5 mg, 10 mg & 20 mg caps, 10 mg/mL liquid
2 mg, 4 mg & 8 mg tabs, 3.2 mg/mL liquid
5 mg & 10 mg tabs, 1 mg/mL liquid
10 mg supp
25 mg, 100 mg, 200 mg & 300 mg tabs
mirtazapine
moclobemide
nortriptyline
paroxetine
sertraline
trazodone
trimipramine
venlafaxine
28:16.08 Antipsychotics
aripiprazole
aripiprazole
chlorpromazine
chlorpromazine
clozapine
flupentixol
flupentixol decanoate
fluphenazine decanoate
oral
injection
injection
oral
oral
oral
rectal
oral
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
Health Canada Advisory (March 2014)
Association of Remeron / Remeron RD
(mirtazapine) with QT Prolongation/Torsades de
Pointes
HCD-28
HCD-25
HCD-07
HCD-28
11
Calgary LTC Formulary - Medication Listing
AHFS Class Generic Name
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
Relevant
Formulary
Links
Health Canada Advisory (Feb 2015): the
indication for risperidone in dementia has been
restricted to the short-term symptomatic
management of aggression or psychotic
symptoms in patients with severe dementia of
the Alzheimer type unresponsive to non-pharm
0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg & 4 mg tabs, 0.5
mg, 1 mg, 2 mg, 3 mg & 4 mg ODT tabs, 1mg/mL
liquid
25 mg/vial, 37.5 mg/vial & 50 mg/vial
1 mg, 2 mg & 5 mg tabs
1 mg/mL
10 mg & 25 mg tabs
50 mg/mL & 200 mg/mL
oral
injection
oral
injection
oral
injection
12:28.20 - Respiratory and CNS Stimulants
methylphenidate
Ritalin
5 mg, 10 mg & 20 mg tabs
oral
28:24 Anxiolytics, Sedatives and Hypnotics
buspirone
Buspar
chloral hydrate
LCA
clonazepam
Rivotril
10 mg tab
500 mg/5mL liquid
0.25 mg, 0.5 mg, & 2 mg tabs
oral
oral
oral
RS-03
Valium
Valium
Atarax
Ativan, Ativan SL
Ativan
Versed
Serax
Restoril
Imovane
2 mg & 5 mg tabs
5 mg/mL
10 mg, 25 mg & 50 mg caps, 10 mg/5mL liquid
0.5 mg, 1 mg & 2 mg tabs, 0,5 mg & 1 mg SL tabs
4 mg/mL
1 mg/mL, 5 mg/mL
10 mg & 15 mg tabs
15 mg & 30 mg caps
5 mg & 7.5 mg tabs
oral
injection
oral
oral/sublingual
injection
injection
oral
oral
oral
RS-12
Carbolith
150 mg & 300 mg caps
oral
risperidone
risperidone
trifluoperazine
trifluoperazine
zuclopenthixol
zuclopenthixol
diazepam
diazepam
hydroxyzine
lorazepam
lorazepam
midazolam
oxazepam
temazepam
zopiclone
28.28 – Antimanic Agents
lithium carbonate
Risperdal
Risperdal Consta
Stelazine
Stelazine
Clopixol
Clopixol Depot
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
HCD-28
Typically restricted to use by neurology
RS-12
RS-11
reserved for use in palliative care
28.36 – Antiparkinsonism Agents
amantadine
bromocriptine
entacapone
note: use in movement disorders is
considered a regular LTC benefit and is
not applicable to HCD-03)
Symmetrel
Parlodel
Comtan
100 mg cap, 10 mg/mL
2.5 mg & 5 mg tabs
200 mg tab
oral
oral
oral
levodopa / carbidopa
Sinemet, Sinemet CR
100mg*10mg, 100mg*25mg & 250mg*25mg tabs,
100mg*25mg & 200mg*50mg CR tabs
oral
RS-35
levodopa / benserazide
Prolopa
50mg*12.5mg & 100mg*25mg caps
oral
RS-35
Approved for use when prescribed for
the management of parkinsonian
symptoms.
Approved for use when prescribed for
the management of parkinsonian
symptoms.
12
Calgary LTC Formulary - Medication Listing
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
pramiprexole
Mirapex
0.25 mg, 1 mg & 1.5 mg tabs
oral
RS-27
ropinirole
Requip
0.25 mg, 0.5 mg, 1 mg, 2 mg & 5mg tabs
oral
RS-27
selegiline
Eldepryl
5 mg tab
oral
RS-35
28:36.08 Anticholinergic Agents
benztropine mesylate
benztropine mesylate
procyclidine
trihexyphenidyl
Cogentin
Cogentin
Kemadrin
Artane
1 mg & 2 mg tabs
1 mg/mL
2.5 mg & 5 mg tabs
2 mg & 5 mg tabs
oral
injection
oral
oral
28:92 Miscellaneous
betahistine
memantine
Serc
Ebixa
16 mg tab
10 mg tab
oral
oral
HCD-09
Nitoman
25 mg tab
oral
RS-11
To be used only when prescribed by a
Neurologist, Geriatrician or Psychiatrist
ASL-01
1000 mg chew tabs (Tums Ultra), 500
mg chew tabs (Tums Regular) are nonformulary -see ASL-01
AHFS Class Generic Name
tetrabenazine
40:00 ELECTROLYTE, CALORIC AND WATER BALANCE AND ENZYMES
amiloride
Midamor
5mg tab
calcium carbonate
calcium glucoheptonate
calcium polystyrene
sulfonate
chlorthalidone
dornase alpha
ethacrynic acid
furosemide
furosemide
hydrochlorothiazide
hydrochlorothiazide /
amiloride
indapamide
lactulose
magnesium salts
metolazone
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
To be used only where prescribed by a
neurologist or geriatrician, and must be
seen by the specialist while on drug
treatment to assess for continuance of
therapy.
To be used only where prescribed by a
neurologist or geriatrician, and must be
seen by the specialist while on drug
treatment to assess for continuance of
therapy.
Approved for use when prescribed for
the management of parkinsonian
symptoms.
oral
Apo-Cal, Tums Extra
Calcium Rougier
1250 mg tab, 750 mg chew tab
100 mg/5mL liquid
oral
oral
Resonium
Thalitone
Pulmozyne
Edecrin
Lasix
Lasix
Hydrodiuril
powder
50 mg tab
non-formulary for LTC
25 mg tab
20 mg, 40 mg and 80 mg tabs
20 mg/2mL
12.5 mg, 25 mg & 50mg tab
oral
oral
Moduret
Lozide
Chronulac
single entity
Zaroxolyn
50mg*5mg tab
1.25 mg & 2.5 mg tabs
667 mg/mL liquid
all formulations (LCA)
2.5 mg & 5mg tabs
oral
oral
oral
oral
oral
LTC Exemption
oral
oral
injection
oral
13
Calgary LTC Formulary - Medication Listing
AHFS Class Generic Name
phosphorus (sodium
phosphate monobasic)
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
Phosphate Novartis
500 mg effervescent tablets
K-10, K-Dur, Micro-K, SlowK
8 mEq K+/tab, 20 mEq K+/tab, 20 mEq K+/15 mL
LCA
all formulations (LCA)
oral
LCA
Kayexalate
Aldactone
all formulations (LCA)
powder
25 mg & 100 mg tabs
oral
oral
oral
Dyazide
LCA
50mg*25mg tab
sterile water
oral
injection
48:00 Antitussives & Expectorants
codeine phosphate
dextromethorphan
dextromethorphan SR
guaifenesin
acetylcysteine
LCA brand
LCA brand
Delsym
LCA brand
Mucomyst
5 mg/mL liquid
15 mg/5mL, 30 mg/5mL liquid
non-formulary, autosub to dextromethorphan
100 mg/5mL liquid
20% solution
oral
oral
oral
oral
inhaled (oral)
48:10.32 Mast Cell Stabilizers
sodium cromoglycate
Cromolyn, Opticrom
2% eye drops
ophthalmic
50 mcg
inhaled (oral)
potassium chloride
sodium bicarbonate
sodium chloride
sodium polystyrene
spironolactone
triamterene /
hydrochlorothiazide
water
48:12:08 Respiratory Tract Anticholinergic Agents
glycopyrronium
Seebri
52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS
chlorhexidine
ciprofloxacin
dexamethasone /
neomycin / polymixin B
erythromycin
framycetin / gramicidin /
dexamethasone
fusidic acid
gatifloxacin
moxifloxacin
ofloxacin
prednisolone /
sulfacetamide
polymyxin B / bacitracin
polymyxin B / gramicidin
tobramycin
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
oral
oral
saline (sodium chloride 0.9%) nebules
are subject to NF approval process
ASL-01
Peridex
Ciloxan
**NOTE: due to short expiry dates for opthalmic products, products should be supplied in the smallest bottle sizes as appropriate.
To be used only for short-term use when
0.12% oral rinse
oral
prescribed by a Dentist
RS-11
0.3% eye drop, 0.3% eye ointment
ophthalmic
Maxitrol
LCA brand
0.1% eye drop, 0.1% eye ointment
0.5% eye ointment
ophthalmic
ophthalmic
Sofracort
Fucithalmic
Zymar
Vigamox
Ocuflox
5 mg/mL*0.05 mg/mL*5 mg/mL drops
1% eye drops
0.3% eye drops
0.5% eye drops
0.3% eye drops
otic/opthalmic
ophthalmic
ophthalmic
ophthalmic
ophthalmic
Blephamide
Polysporin Ophthalmic
Ointment
Polysporin Eye and Ear
Drops
Tobrex
0.2%*10% eye drops, eye ointment
ophthalmic
10 000unit/g*500unit/g eye ointment
ophthalmic
10 000unit/mL*0.025mg/mL drops
0.3% eye drop, 3 mg/g eye ointment
otic/opthalmic
ophthalmic
14
Calgary LTC Formulary - Medication Listing
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
Tobradex
Viroptic
0.3%*0.1% eye drop, eye ointment
1% eye drop
ophthalmic
ophthalmic
Beconase Aq
Rhinocort
Maxidex
Voltaren Ophtha
50 mcg/dose
non-formulary - autosub to beclomethasone
0.1% eye drops, 0.1% eye ointment
0.1% eye drops
inhaled (nasal)
inhaled (nasal)
ophthalmic
ophthalmic
Locacorten Vioform
Rhinalar
Flonase
Acular
Nasonex
Nevanac
Pred Forte, Pred Mild
Nasocort AQ
0.02%*1% ear drops
non-formulary - autosub to beclomethasone
non-formulary - autosub to beclomethasone
non-formulary - autosub to diclofenac
non-formulary - autosub to beclomethasone
non-formulary - autosub to diclofenac
1%*0.12% eye drops
non-formulary - autosub to beclomethasone
otic
inhaled (nasal)
inhaled (nasal)
ophthalmic
inhaled (nasal)
ophthalmic
ophthalmic
inhaled (nasal)
52:40 Carbonic Anydrase Inhibitors
acetazolamide
brinzolamide
brinzolamide / timolol
dorzolamide
dorzolamide / timolol
Diamox
Azopt
Azarga
Trusopt
Cosopt
250 mg tab
1% eye drops
1%*0.5% eye drops
2% eye drops
2%*0.5% eye drops
oral
ophthalmic
ophthalmic
ophthalmic
ophthalmic
52:40 Prostaglandin Analogs
bimatoprost
latanoprost
latanoprost / timolol
travoprost
Lumigan
Xalatan
Xalacom
Travatan Z
non-formulary - autosub to latanoprost
0.005% eye drops
0.005%*0.5% eye drops
non-formulary - autosub to latanoprost
ophthalmic
ophthalmic
ophthalmic
ophthalmic
Isopto Atropine
Tantum
Betoptic-S
Lumigan
Alphagan
1% eye drops
0.15% liquid
0.25% eye drops
non-formulary - autosub to latanoprost
0.2% eye drops
ophthalmic
oral rinse
ophthalmic
RS-14
ophthalmic
RS-14
Mois-Stir
liquid spray
oral
Celluvisc
Refresh
Betagan
Xylocaine
LCA
1% eye drops (unpreserved)
1% eye drops (with purite preservative)
0.5% eye drops
2% viscous oral solution
mineral oil light
ophthalmic
ophthalmic
ophthalmic
oral
otic
AHFS Class Generic Name
tobramycin /
dexamethasone
trifluridine
52:08 (EENT) Corticosteroids
beclomethasone
budesonide
dexamethasone
diclofenac ophthalmic
flumethasone / clioquinol
flunisolide
fluticasone
ketorolac
mometasone
nepafenac
prednisolone
triamcinolone
52:00 Miscellaneous
atropine
benzydamine
betaxolol
bimatoprost
brimonidine
carboxymethylcellulose/el
ectrolytes
carboxymethylcellulose
carboxymethylcellulose
levobunolol
lidocaine
mineral oil
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
preferred nasal corticosteroid
ASL-01
ASL-01
ASL-01
ASL-01
ASL-01
ASL-01
ASL-01
RS-14
RS-14
RS-14
RS-14
ASL-01
preferred prostaglandin analogue
ASL-01
ASL-01
preferred preservative-free ophthalmic
lubricant
preferred ophthalmic lubricant
ASL-01
autosub for Cerumenex ®
ASL-01
RS-11
15
Calgary LTC Formulary - Medication Listing
AHFS Class Generic Name
ophthalmic lubricant
without preservative (unit
dose)
ophthalmic lubricant with
preservative
ophthalmic lubricant
ointment
pilocarpine
polyethylene/ propylene
glycol
sodium chloride
hypertonic
tetracaine
timolol
white petrolatum, mineral
oil
xylometazoline
56:00 GASTROINTESTINAL DRUGS
56:04 Antacids & Adsorbents
activated charcoal
aluminum hydroxide /
magnesum hydroxide
aluminum hydroxide /
magnesum hydroxide /
simethicone
alginic acid, magnesium
carbonate
sodium alginate,
aluminum hydroxide
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
any brand
autosub to preservative-free carboxymethylcellulose
(Cellevisc)
autosub to carboxymethylcellulose with purite
preservative (Refresh)
any brand
Isopto-carpine
autosub to white petrolatum, mineral oil (Lacri-lube)
1%, 2% & 4% eye drops
ophthalmic
ophthalmic
Secaris
nasal gel
nasal
Muro 128
Pontocaine
Timoptic, Timoptic XE
5% eye drops, 5% eye ointment
0.5% eye drops
0.25%, 0.5% eye drops
ophthalmic
ophthalmic
ophthalmic
Lacri-lube
Otrivin
gel
0.05% & 0.1% nasal spray
ophthalmic
nasal
Charac, Charactol
25 g & 50 g (aqueous), 25 g & 50 g (in sorbitol)
oral
Almagel
40mg/ml*40mg/mL liquid
oral
Almagel Plus
40mg/mL*40mg/mL*5mg/mL liquid
oral
Gaviscon
200mg*40mg tab
oral
Gaviscon
50mg/mL*20mg/mL liquid
oral
2 mg tab
oral
any brand
56:00 Antidiarrhea and Antiflatulent Agents
loperamide
Imodium
saccharomyces boulardii
simethicone
56:12 Cathartics & Laxatives
bisacodyl
bisacodyl
cascara sagrada
electrolyte solutions
glycerin
Route of
Adminstration
Relevant
Formulary
Links
ophthalmic
ASL-01
ophthalmic
ASL-01
ASL-01
Florastor
Ovol
5 billion live cells/250 mg cap
80 mg & 180 mg tab
oral
oral
Dulcolax
Dulcolax
Cascara
5 mg tab
10 mg supp
non-formulary - autosub to senna
oral
rectal
oral
Colyte, Gastrolyte
LCA
powder
2.7 g supp
oral
rectal
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
RS-11
RS-14
ASL-01
preferred ophthalmic lubricant ointment
RS-20
preferred formulary probiotic;
conditionally limited to therapy
concurrent with antibiotics (up to 2
weeks after cessation of antibiotics) see RS-20 for detail
ASL-01
16
Calgary LTC Formulary - Medication Listing
AHFS Class Generic Name
lactulose
magnesium citrate
magnesium hydroxide
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Chronulac
667 mg/mL liquid
Citro-Mag
0.05 g/mL liquid
Milk of Magnesia
Route of
Adminstration
oral
oral
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
80 mg/mL liquid
non-formulary - autosub to Milk of Magnesia
oral
oral
Restoralax, Lax-a-day
Metamucil
Senokot
powder
powder, sugar-free powder
8.6 mg tab
oral
oral
oral
Microlax
90mg/mL*9mg/mL*625mg/mL enema
rectal
Fleet
0.06g/mL*0.16g/mL enema
rectal
56:16 Digestants
pancrelipase (LipaseAmylase-Protease)
Pancrease, Cotazym,
Creon, Viokase, Ultrase
all formulations
oral
56:22 Antihistamines
dimenhydrinate
dimenhydrinate
dimenhydrinate
Gravol
Gravol
Gravol
50 mg tab
25 mg, 50 mg and 100 mg supp
50 mg/mL
oral
rectal
injection
non-formulary (autosub to rabeprazole)
non-formulary (autosub to rabeprazole)
non-formulary (autosub to ranitidine)
non-formulary (autosub to rabeprazole)
15 mg & 30 mg dissolving tabs
100 mcg & 200 mcg tabs
oral
oral
oral
oral
oral
ASL-05
non-formulary (autosub to rabeprazole)
non-formulary (requires NF application)
non-formulary (autosub to rabeprazole)
oral
oral
oral
ASL-05
ASL-05
RS-04
pantoprazole magnesium Tecta
rabeprazole
Pariet
non-formulary (autosub to rabeprazole)
10 mg & 20 mg tabs
oral
oral
ASL-05
RS-04
ranitidine
150 mg & 300 mg tabs
oral
magnesium hydroxide/parrafin Magnolax
polyethylene glycol 3350
psyllium mucilloid
sennosides
sodium citrate / sodium
lauryl sulfoacetate /
sorbitol
sodium phosphate dibasic
/ sodium phosphate
monobasic
56:28 Antiulcer agents & Acid suppressants
dexlansoprazole
Dexilant
esomeprazole
Nexium
famotidine
Pepcid
lansoprazole
Prevacid
lansoprazole
Prevacid Fastabs
misoprostol
Cytotec
omeprazole
omeprazole
pantoprazole
Losec
compounded liquid
Pantoloc
Zantac
ASL-01
ASL-05
RS-04
ASL-05
RS-04
ASL-01
RS-04
approved for use via enteral tube
RS-04
RS-04
20 mg caps approved for use in clients
with modified diet requirements
RS-04
RS-04
75mg/5ml liquid is subject to NF
approval process
56:32 Prokinetic Agents
17
Calgary LTC Formulary - Medication Listing
AHFS Class Generic Name
domperidone
metoclopramide
metoclopramide
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
Motilium
Maxeran
Maxeran
10 mg tab
5 mg & 10 mg tabs, 1 mg/mL liquid
5 mg/mL
oral
oral
injection
Asacol, Mesasal,
Mezavant, Novo-5-ASA,
Pentasa, Salofalk
Salofalk, Pentasa
all strengths and oral formulations
all strengths and rectal formulations
oral
rectal
50 mcg/dose & 100 mcg/dose
inhaled (oral)
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
Health Canada Advisory (March 2012) - The risk
of serious ventricular arrhythmias or sudden
cardiac death may be higher in patients taking
daily doses greater than 30 mg, and in patients
older than 60 years of age
56:36 Anti-Inflammatory Agents
mesalamine (mesalazine,
5-ASA)
meselamine (5-ASA)
68:00 HORMONES & SYNTHETIC SUBSTITUTES
68:04 Adrenals
beclomethasone
QVAR MDI
budesonide
Entocort
budesonide
budesonide
dexamethasone
dexamethasone
fludrocortisone
Pulmicort nebules
Pulmicort Turbuhaler
LCA
Decadron
Florinef
fluticasone
hydrocortisone
methylprednisolone
methylprednisolone
prednisone
triamcinolone
68:16.04 Estrogens
estradriol-17β
estrogen, conjugated
3mg cap
oral
inhaled (oral)
inhaled (oral)
oral
injection
oral
Flovent MDI, diskus
Cortef
Medrol
Depo-Medrol
Deltasone
Kenalog
0.125 mg/mL & 0.25 mg/mL nebules
Non-formulary - autosub to fluticasone MDI
0.5 mg & 4 mg tabs
10 mg/mL
0.1 mg tab
125 mcg/dose & 250mcg/dose MDI, 100 mcg/dose &
250 mcg/dose diskus
10mg tab
4 mg tab
40 mg/mL
1 mg, 5 mg & 50 mg tab
10 mg/mL & 40 mg/mL
Vagifem
10 mcg tab
vaginal
Premarin
0.3 mg, 0.625 mg, 0.9 mg & 1.25 mg tabs
oral
RS-45
Restricted for treatment of
inflammatory bowel disease and
prescription by gasteroenterology,
internal medicine, or general surgery
RS-21
Max of 72 hours of therapy, PRN or
routine, when patient in acute
respiratory distress or tapered therapy
for maximum of 120 days when client
has significant psychological addiction to
nebulized medications
ASL-01
inhaled (oral)
oral
oral
injection
oral
injection
RS-43
restricted for menopausal/genitourinary
symptoms
18
Calgary LTC Formulary - Medication Listing
AHFS Class Generic Name
estrogen, conjugated
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
Premarin
0.625 mg/g cream
vaginal
Diamicron, Diamicron MR
Diabeta
Glucophage
80 mg tab, 30 mg & 60 mg MR tabs
2.5 mg & 5 mg tabs
500 mg & 850 mg tabs
oral
oral
oral
Relevant
Formulary
Links
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
RS-43
restricted for menopausal/genitourinary
symptoms
RS-37
for use in diabetes treatment in clients
with renal impairment, or with prior
treatment failure with other agents
To be used only for hypoglycemic
treatments when client is unconscious or
otherwise unable to take oral glucose
68:20 Antidiabetic Agents
gliclazide
glyburide
metformin
repaglinide
Gluconorm
0.5 mg, 1 mg & 2 mg tabs
oral
68:22 Glycogenolytic Agents
glucagon
Glucagon
1 mg/vial
injection
RS-11
Novorapid
Levemir
Lantus
Humalog
Humulin N, Novolin NPH,
Novolin GE 30/70
Humulin R, Novolin R,
Novoloin GE 30/70
any brand
100 unit/mL
100 unit/mL
100 unit/mL
100 unit/mL
injection
injection
injection
injection
RS-40
100 unit/mL
injection
100 unit/mL
100 unit/mL
injection
injection
Calcimar
200 unit/mL
injection
RS-33
desmopressin
DDAVP
0.1 mg & 0.2 mg tabs
oral
RS-11
desmopressin
DDAVP
0.1 mg/mL
nasal spray
RS-11
levothyroxine
medroxyprogesterone
oral contraceptives
thiamazole
Eltroxin, Synthroid
Provera
all brands (LCA)
Tapazole
all strengths
2.5 mg & 5 mg tabs
all strengths
5 mg
oral
oral
oral
oral
Xylocaine
1% injection
injection
68:20.08 Insulins
insulin aspart
insulin detemir
insulin glargine
insulin lispro
insulin NPH (human)
insulin regular (human)
insulins (mixed)
68:00 Miscellaneous Agents
calcitonin
72:00 Local Anesthetics
lidocaine
RS-44
RS-44
RS-40
To be used only when prescribed by a
neurologist or endocrinologist
To be used only when prescribed by a
neurologist or endocrinologist
RS-43
84:00 SKIN & MUCOUS MEMBRANE AGENTS
19
Calgary LTC Formulary - Medication Listing
AHFS Class Generic Name
84:04 Anti-infectives
ciclopirox
clotrimazole
clotrimazole
fusidic acid
ketoconazole
ketoconazole
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
Loprox
Canesten, Clotrimaderm
Canesten, Clotrimaderm
Fucidin
Nizoral
Nizoral
topical
topical
vaginal
topical
topical
topical
ASL-01
vaginal
ASL-01
topical
topical
topical
ASL-01
Relevant
Formulary
Links
metronidazole
Nidagel
metronidazole
miconazole
mupirocin
Metrogel, Metrocream
Monistat
Bactroban
non-formulary - autosub to clotrimazole cream
1% cream, powder
1% & 2% cream
2% cream, 2% ointment
non-formulary - autosub to clotrimazole cream
shampoo
0.75% gel (10% vaginal cream autosub to 0.75%
vaginal gel)
0.75% gel, 0.75% cream (Metrogel 1% autosubbed to
Metrogel 0.75%)
non-formulary - autosub to clotrimazole cream
non-formulary - autosub to Polysporin
nystatin
nystatin
permethrin
polymyxin B / bacitracin
Mycostatin
Mycostatin
Kwelleda-P, Nix
Polysporin, Polytopic
100 000 unit/g cream, powder
25 000 unit/g cream
1% cream rinse, 5% cream, 5% lotion
10 000units/g*500 units/g ointment
topical
vaginal
topical
topical
polymyxin B / gramicidin
selenium sulfide
silver sulfadiazine
Polysporin
Selsun
Flamazine
topical
topical
topical
terbinafine
tolnaftate
Lamisil
Tinactin
10 000units/g*0.25mg/g cream
2.5% shampoo
1% cream
1% cream (autosub to clotrimazole 1% unless RS
criteria met)
powder, aerolized powder, spray, cream
topical
topical
ASL-01
0.1% cream, 0.1% ointment, 0.1% lotion
0.05% & 0.1% cream, 0.05% & 0.1% ointment, 0.1%
lotion, 0.1% scalp lotion
topical
ASL-01
betamethasone valerate
Cyclocort
Betnovate, Celestoderm,
Valisone
topical
ASL-01
clioquinol-flumethasone
Locacorten Vioform
non-formulary (autosub to betamethasone / nystatin) topical
ASL-01
clobetasol 17-propionate
hydrocortisone
Dermovate
Cortate
0.05%, cream, 0.05% ointment, 0.05% scalp lotion
0.5% & 1% cream, 0.5% & 1% ointment
topical
topical
ASL-01
triamcinolone acetonide
hydrocortisone / zinc
sulfate
Oracort dental
0.1% paste
topical
Anusol-HC, Anodan-HC
0.5%*0.5% ointment, 10mg*10mg supps
rectal
5% & 10% lotions, 5% gel
topical
0.5%, 1% and for use in compounding
topical
RS-23
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
RS-17
RS-23
ASL-01
RS-11
For treatment of rosacea
ASL-01
ASL-01
Nystatin Topical Powder in Talc 100,000
units/gram -refer AHS compound recipe
note: expiry 7 days when opened
RS-17
RS-23
84:06 Anti-inflammatory Agents
amcinonide
84:08 Antipruritics, Local Anesthetics
benzoyl peroxide
Benoxyl, Panoxyl
Neutrogena T-Gel, T-Gel
coal tar
Extra
preferred high potency corticosteroid
preferred medium potency
corticosteroid
preferred low potency corticosteroid
20
Calgary LTC Formulary - Medication Listing
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
Route of
Adminstration
Proctosedyl, RatioProctosone
Xylocaine
Uremol
Uremol HC
Anusol
5mg*10mg*5mg*10 mg supps, 0.5%*1%*0.5%*1 %
ointment
2% jelly, 5% ointment
10% & 20% creams, 10% lotion
10-1% cream., 10-1% lotion
0.5% ointment
rectal
topical
topical
topical
rectal
Dovobet
Dovonex
50mcg/g*0.5mg/g ointment, 50mcg/g*0.5mg/g gel
50 mcg/g ointment
topical
topical
Efudex
Aldara
5% cream
5% cream
topical
topical
86:00 SMOOTH MUSCLE RELAXANTS
darifenacin
oxybutynin
solifenacin
theophylline
tolterodine L-tartrate
Enablex
Ditropan
Vesicare
Theo-Dur
Detrol, Detrol LA
non-formulary - autosub to solifenacin
2.5 mg & 5 mg tabs
5 mg & 10 mg tabs
100 mg, 200 mg & 300 mg tabs
non-formulary - autosub to solifenacin
oral
oral
oral
oral
oral
88:00 VITAMINS
calcitriol
cholecalciferol
Rocaltrol
Vitamin D3 LCA
0.25 mg & 0.5 mg caps
400 unit & 1000 unit tabs
oral
oral
cyanocobalamin
Vitamin B12 LCA
500 mcg & 1000 mcg tablets (regular release)
oral
cyanocobalamin
folic acid
multivitamin with
minerals (ocular)
multivitamin wth/or
without minerals
multivitamin wth/or
without minerals
Vitamin B12 LCA
Folic Acid LCA
injection
oral
Vitalux AREDs, Ocuvite
1000 mcg/mL
1 mg & 5 mg tabs
LCA AREDs-based product, beta-carotene-free
formulation for smokers
oral
ASL-01
Centrum-type LCA
LCA oral solid product, with or without minerals
oral
ASL-01
Maltlevol-type LCA
LCA oral liquid product, with or without minerals
oral
ASL-01
as supplied
10 mg/mL (for ORAL use)
120 mcg in multivitamin (LCA-type), 120mcg*1000
unit tab
50 mg & 100 mg tabs
50 mg & 100 mg tabs
400 unit cap
oral
injection
RS-05
AHFS Class Generic Name
hydrocortisone /
framycetin / cichocaine /
esculin
lidocaine
urea
urea-hydrocortisone
zinc sulfate
84:92 Miscellaneous Agents
calcipotriol /
betamethasone
dipropionate
calcipotriol
fluorouracil (5-FU)
imiquimod
multivitamin plain (renal) Replavite
phytonadione
Vitamin K1
Vitamin K1, Webber K1 /
phytonadione
Vitamin D
pyridoxine
Vitamin B6 LCA
thiamine
Vitamin B1 LCA
Vitamin E
Vitamin E LCA
Relevant
Formulary
Links
RS-11
RS-11
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
restricted to use by dermatologist
restricted to use by dermatologist
may be covered by TBCC for squamous
cell carcinoma and other cancers
HCD-02
ASL-01
preferred smooth muscle relaxant
ASL-01
ASL-01
all oral formulations autosub to regular
release product
should convert to oral product when
possible
may be given for oral administration
oral
oral
oral
oral
21
Calgary LTC Formulary - Medication Listing
AHFS Class Generic Name
Revised June 1, 2016
Brand Name & Synonyms
(LCA to be dispensed when
available)1
Strength
92:00 MISCELLANEOUS THERAPEUTIC AGENTS
allopurinol
Zyloprim
azathioprine
Imuran
cyproterone
incobotulinum toxin A
onabotulinum toxin A
colchicine
dutasteride
finasteride
92:24 Bone Resorption Inhibitors
alendronate
clodronate
etidronate
risedronate
Route of
Adminstration
Relevant
Formulary
Links
100 mg, 200 mg & 300 mg tabs
50 mg tab
oral
oral
Androcur
Xeomin
Botox
LCA
Avodart
Proscar
50 mg tab
100 unit/vial
100 unit/vial
0.6 mg tab
0.5 mg cap
5 mg tab
oral
injection
injection
oral
oral
oral
RS-42
Fosamax
non-formulary - autosub to risedronate
oral
ASL-01
Bonefos
Didrocal
Actonel
400 mg cap
non-formulary - autosub to risedronate
35 mg (all other strengths autosub to 35 mg)
oral
oral
oral
Relevant
Formulary Formulary Considerations (and
Links 2
applicable Health Canada Advisories)
restricted for use in treatment of
inappropriate sexual behaviors
HCD-16
HCD-16
RS-13
RS-13
RS-11
To be used only when a diagnosis of
breast cancer, bone metastasis exists,
and when ordered by an oncologist
ASL-01
ASL-01
preferred formulary bisphosphonate
22