` Check box for Stat Orders
Telephone Order: Write down, Read Back provided to confirm order accuracy
Verbal Order: Emergency only. Repeat Back provided to confirm order accuracy
254 EASTON AVENUE, P.O. BOX 591, NEW BRUNSWICK, NEW JERSEY 08903-0591
DATE ________/_______/________ Patient Name:
TIME __________ : _____________ Patient FIN :
AM PM Patient Location:
PHARMACY AUTOMATIC SUBSTITUTION ORDER FORM
Respiratory Agents
Order Written : Pharmacy Dispensed :
XOPENEX AUTOMATIC SWITCH ONLY APPLY TO ADULTS
 Xopenex (Levalbuterol) neb.soln. 0.63mg q6h Albuterol neb.soln. 1.25mg q6h
 Xopenex neb.soln. 0.63mg q8h Albuterol neb.soln. 1.25mg q8h
 Xopenex neb.soln. 1.25 mg q6h Albuterol neb.soln. 2.5mg q6h
 Xopenex neb.soln. 1.25 mg q8h Albuterol neb.soln. 2.5mg q8h
 Xopenex 1.25 mg any frequency greater than every 8 hours Albuterol 2.5mg mg q8h -Add a prn order for every 2hours if none exist
 Xopenex 0.63mg any frequency greater than every 6 hours Albuterol 1.25mg q6h -Add a prn order for every 2 hours if none exist
 Theodur® (theophylline timed-release) 200 mg BID Unidur® (theophylline extended release-24 hr) 400mg DAILY
 Theodur® (theophylline timed-release) 300 mg BID Unidur® (theophylline extended release-24 hr) 600mg DAILY
 Serevent® Inhalation Aerosol 2 puffs BID Serevent® Diskus 1 puff BID
 Nasonex (Mometasone) Flonase (Fluticasone) - Same dose and frequency
Cardiovascular Agents
 Cardizem CD® (diltiazem extended release) Tiazac® (diltiazem extended release)- Same dose and frequency
 Dilacor® XR (diltiazem extended release) Tiazac® Same dose and frequency
 Fragmin® (dalteparin) 5000 units once daily Lovenox® (enoxaparin) 40mg once daily
 Avapro (Irbesartan) 150 mg (Max: 300 mg per day) Cozaar (Losartan) 50 mg (Max: 100 mg per day)
 Avalide 150mg PO Daily Cozaar 50mg + Hydrochlorthiazide 12.5 mg PO Daily
 Avalide 300mg / 12.5mg PO Daily Cozaar 100mg + Hydrochlorthiazide 12.5 mg PO Daily
 Avalide 300mg / 25 mg PO Daily Cozaar 100mg + Hydrochlorthiazide 25 mg PO Daily
 Micardis (Telmisartan) 40 mg (Max: 80 mg per day) Cozaar (Losartan) 50 mg (Max: 100 mg per day)
NON-FORMULARY STATIN WRITTEN : Pharmacy Dispensed:
*Atorvastatin Pravastatin Rosuvastatin Fluvastatin Lovastatin *Simvastatin
Lipitor Pravachol Crestor Lescol Mevacor Zocor
-  10mg - -  10mg 5mg
-  20mg -  20mg  20mg 10mg
 10mg  40mg  5mg  40mg  40mg 20mg
 20mg  80mg  10mg  80mg XL - 40mg
 40mg - - - - 80mg
Greater than 40mg - 20mg or Greater - - Do Not Switch
 Coreg CR 10mg po daily Carvedilol (Coreg) 3.125mg po BID
 Coreg CR 20mg PO daily Carvedilol (Coreg) 6.25mg po BID
 Coreg CR 40mg PO daily Carvedilol (Coreg) 12.5mg PO BID
 Coreg CR 80mg PO daily Carvedilol (Coreg) 25mg po BID
 Atacand (Candesartan) 8 mg (Max: 32 mg per day) Diovan (Valsartan) 80 mg (Max: 320 mg per day)
 Benicar (Olmesartan) 10 mg (Max: 40 mg per day) Diovan (Valsartan) 80 mg (Max: 320 mg per day)
 Potassium Chloride 10mEq IV piggyback (Any Solution) Potassium Chloride IV piggyback 10mEq/100ml SW (sterile water)
 Potassium Chloride 20mEq IV piggyback (Any Solution) Potassium Chloride IV piggyback 20mEq/100ml SW
 Magnesium 1 gm IV piggyback (Any Solution) Magnesium 1 gm in 100mL D5W IV piggyback
 Magnesium 2 gm IV piggyback (Any Solution) Magnesium 2 gm in 50 ml SW IV piggyback
 Aspirin Suppository 325mg - Any Interval Aspirin Suppository 300mg – Same Interval
Caduet PO daily : Amlodipine + Simvastatin PO daily:
 2.5/10 Amlodipine 2.5 mg and atorvastatin 10 mg  Amlodipine 2.5mg + Simvastatin 20mg
 2.5/20: Amlodipine 2.5 mg and atorvastatin 20 mg  Amlodipine 2.5mg + Simvastatin 40mg
 5/10: Amlodipine 5 mg and atorvastatin 10 mg  Amlodipine 5mg + Simvastatin 20mg
 5/20: Amlodipine 5 mg and atorvastatin 20 mg  Amlodipine 5mg + Simvastatin 40mg
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The risk is of myopathy is increased when simvastatin and atorvastatin, both CYP 3A4 substrates, (fluvastatin, lovastatin, rosuvastatin and
pravastatin are not ) are used concomitantly with potent CYP 3A4 inhibitors such as erythromycin, itraconazole, amiodarone, verapamil). Also
Diltiazem, a weaker inhibitor of CYP 3A4, is frequently prescribed with a statin. Diltiazem increases the risk of rhabdomyolysis to 1% when given
with simvastatin 80mg daily. DO NOT SWITCH STATINS IF PATIENTS ARE TAKING THESE DRUGS
Registered Pharmacist ID# DATE TIME
Licensed Physician/Permit Holder ID# DATE TIME
Registered Resident Physician ID# DATE TIME
Order Noted:RN DATE TIME