etoposide (Rx)

Brand and Other Names:VePesid, Toposar, more...Etopophos, vp 16
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

capsule

  • 50mg

injectable solution

  • 20mg/mL

powder for injection

  • 100mg

Testicular Cancer

50-100 mg/m²/day IV on days 1-5, OR  

100 mg/m²/day IV on days 1, 3, 5

Repeat q3-4week

Small-Cell Lung Cancer

35 mg/m²/day IV for 4 days, OR  

50 mg/m²/day IV for 5 days; repeat q3-4week

Monitor

CBC, Hgb, LFTs, renal function

Administration

Equivalent IV doses for etoposide & etoposide phosphate

PO: 2 times IV dose, rounded to nearest 50 mg

Renal Impairment

CrCl >50 mL/min: Dose adjustment not necessary

CrCl 15-50 mL/min: 75% of regular dose

CrCl < 15 mL/min: Not studied; consider further dose reductions

Hepatic Impairment

Not studied

Dosage Forms & Strengths

capsule

  • 50mg

injectable solution

  • 20mg/mL

powder for injection

  • 100mg

AML Induction (Off-label)

<3 years: 3.3 mg/kg/day IV continuous infusion for 4 days  

≥3 years: 100 mg/m²/day IV continuous infusion for 4 days  

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Interactions

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              Serious - Use Alternative (17)

              • abametapir

                abametapir will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. For 2 weeks after abametapir application, avoid taking drugs that are CYP3A4 substrates. If not feasible, avoid use of abametapir.

              • adenovirus types 4 and 7 live, oral

                etoposide decreases effects of adenovirus types 4 and 7 live, oral by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressives may diminish therapeutic effects of vaccines and increase risk of adverse effects (increased risk of infection). Live-attenuated vaccines should be avoided for at least 3mo after cessation of immunosuppressive therapy.

              • apalutamide

                apalutamide will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of apalutamide, a strong CYP3A4 inducer, with drugs that are CYP3A4 substrates can result in lower exposure to these medications. Avoid or substitute another drug for these medications when possible. Evaluate for loss of therapeutic effect if medication must be coadministered. Adjust dose according to prescribing information if needed.

              • enzalutamide

                enzalutamide will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

              • erdafitinib

                erdafitinib will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If coadministration unavoidable, separate administration by at least 6 hr before or after administration of P-gp substrates with narrow therapeutic index.

              • fexinidazole

                fexinidazole will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Fexinidazole inhibits CYP3A4. Coadministration may increase risk for adverse effects of CYP3A4 substrates.

              • idelalisib

                idelalisib will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Idelalisib is a strong CYP3A inhibitor; avoid coadministration with sensitive CYP3A substrates

              • influenza virus vaccine quadrivalent, adjuvanted

                etoposide decreases effects of influenza virus vaccine quadrivalent, adjuvanted by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive drugs may reduce the immune response to influenza vaccine.

              • influenza virus vaccine trivalent, adjuvanted

                etoposide decreases effects of influenza virus vaccine trivalent, adjuvanted by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Immunosuppressive drugs may reduce the immune response to influenza vaccine.

              • ivosidenib

                ivosidenib will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP3A4 substrates with ivosidenib or replace with alternate therapies. If coadministration is unavoidable, monitor patients for loss of therapeutic effect of these drugs.

              • lonafarnib

                etoposide will increase the level or effect of lonafarnib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If coadministration of lonafarnib (a sensitive CYP3A substrate) with weak CYP3A inhibitors is unavoidable, reduce to, or continue lonafarnib at starting dose. Closely monitor for arrhythmias and events (eg, syncope, heart palpitations) since lonafarnib effect on QT interval is unknown.

              • nefazodone

                nefazodone will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

              • palifermin

                palifermin increases toxicity of etoposide by Other (see comment). Avoid or Use Alternate Drug. Comment: Palifermin should not be administered within 24 hrbefore, during infusion of, or within 24 hr after administration of antineoplastic agents. Coadministration of palifermin within 24 hr of chemotherapy resulted in increased severity and duration of oral mucositis.

              • sotorasib

                sotorasib will decrease the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If use is unavoidable, refer to the prescribing information of the P-gp substrate for dosage modifications.

              • tepotinib

                tepotinib will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Avoid or Use Alternate Drug. If concomitant use unavoidable, reduce the P-gp substrate dosage if recommended in its approved product labeling.

              • tucatinib

                tucatinib will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid concomitant use of tucatinib with CYP3A substrates, where minimal concentration changes may lead to serious or life-threatening toxicities. If unavoidable, reduce CYP3A substrate dose according to product labeling.

              • voxelotor

                voxelotor will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Voxelotor increases systemic exposure of sensitive CYP3A4 substrates. Avoid coadministration with sensitive CYP3A4 substrates with a narrow therapeutic index. Consider dose reduction of the sensitive CYP3A4 substrate(s) if unable to avoid.

              Monitor Closely (109)

              • acalabrutinib

                acalabrutinib, etoposide. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Coadministration may increase risk of myelosuppressive effects.

              • amiodarone

                amiodarone will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • amobarbital

                amobarbital will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • apalutamide

                apalutamide will decrease the level or effect of etoposide by increasing elimination. Use Caution/Monitor. Apalutamide induces UGT and may decrease systemic exposure of drugs that are UGT substrates.

              • aprepitant

                aprepitant will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • atazanavir

                atazanavir will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • atorvastatin

                atorvastatin will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • avapritinib

                etoposide will increase the level or effect of avapritinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • axitinib

                etoposide increases levels of axitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • belatacept

                belatacept and etoposide both increase immunosuppressive effects; risk of infection. Use Caution/Monitor.

              • belzutifan

                belzutifan will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. If unable to avoid coadministration of belzutifan with sensitive CYP3A4 substrates, consider increasing the sensitive CYP3A4 substrate dose in accordance with its prescribing information.

              • berotralstat

                berotralstat will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Monitor or titrate P-gp substrate dose if coadministered.

              • bosentan

                bosentan will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • bosutinib

                bosutinib increases levels of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • butabarbital

                butabarbital will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • carbamazepine

                carbamazepine will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • cenobamate

                cenobamate will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Increase dose of CYP3A4 substrate, as needed, when coadministered with cenobamate.

              • cimetidine

                cimetidine will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • clarithromycin

                clarithromycin will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                clarithromycin will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • conivaptan

                conivaptan will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • crizotinib

                crizotinib increases levels of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Dose reduction may be needed for coadministered drugs that are predominantly metabolized by CYP3A.

                crizotinib increases levels of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • crofelemer

                crofelemer increases levels of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Crofelemer has the potential to inhibit CYP3A4 at concentrations expected in the gut; unlikely to inhibit systemically because minimally absorbed.

              • cyclosporine

                cyclosporine will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                cyclosporine will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • dabrafenib

                dabrafenib will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.

              • darunavir

                darunavir will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • dasatinib

                dasatinib will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • deferasirox

                deferasirox will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • denosumab

                etoposide, denosumab. Other (see comment). Use Caution/Monitor. Comment: Caution should be taken in patients on concomitant immunosuppressants or with impaired immune systems because of increased risk for serious infections.

              • dexamethasone

                dexamethasone will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • dichlorphenamide

                dichlorphenamide, etoposide. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Both drugs can cause metabolic acidosis.

              • dronedarone

                dronedarone will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                dronedarone will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • efavirenz

                efavirenz will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • elagolix

                elagolix will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Elagolix is a weak-to-moderate CYP3A4 inducer. Monitor CYP3A substrates if coadministered. Consider increasing CYP3A substrate dose if needed.

              • eliglustat

                eliglustat increases levels of etoposide by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Monitor therapeutic drug concentrations, as indicated, or consider reducing the dosage of the P-gp substrate and titrate to clinical effect.

              • elvitegravir/cobicistat/emtricitabine/tenofovir DF

                elvitegravir/cobicistat/emtricitabine/tenofovir DF increases levels of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Cobicistat is a CYP3A4 inhibitor; contraindicated with CYP3A4 substrates for which elevated plasma concentrations are associated with serious and/or life-threatening events.

              • encorafenib

                encorafenib, etoposide. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Encorafenib both inhibits and induces CYP3A4 at clinically relevant plasma concentrations. Coadministration of encorafenib with sensitive CYP3A4 substrates may result in increased toxicity or decreased efficacy of these agents.

              • erythromycin base

                erythromycin base will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                erythromycin base will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • erythromycin ethylsuccinate

                erythromycin ethylsuccinate will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                erythromycin ethylsuccinate will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • erythromycin lactobionate

                erythromycin lactobionate will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                erythromycin lactobionate will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • erythromycin stearate

                erythromycin stearate will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                erythromycin stearate will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • eslicarbazepine acetate

                eslicarbazepine acetate will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • etravirine

                etravirine will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • fedratinib

                fedratinib will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Adjust dose of drugs that are CYP3A4 substrates as necessary.

              • finerenone

                etoposide will increase the level or effect of finerenone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Monitor serum potassium during initiation and dosage adjustment of either finererone or weak CYP3A4 inhibitors. Adjust finererone dosage as needed.

              • fingolimod

                etoposide increases effects of fingolimod by immunosuppressive effects; risk of infection. Modify Therapy/Monitor Closely. Concomitant therapy is expected to increase the risk of immunosuppression. Use caution when switching patients from long-acting therapies with immune effects. .

              • flibanserin

                etoposide will increase the level or effect of flibanserin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Increased flibanserin adverse effects may occur if coadministered with multiple weak CYP3A4 inhibitors.

              • fluconazole

                fluconazole will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • fosamprenavir

                fosamprenavir will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • fosphenytoin

                fosphenytoin will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • fostamatinib

                fostamatinib will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Concomitant use of fostamatinib may increase concentrations of P-gp substrates. Monitor for toxicities of the P-gp substrate drug that may require dosage reduction when given concurrently with fostamatinib.

              • glecaprevir/pibrentasvir

                glecaprevir/pibrentasvir will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • hydroxyurea

                etoposide, hydroxyurea. Other (see comment). Use Caution/Monitor. Comment: Combination may increase risk of myelosuppression.

              • iloperidone

                iloperidone increases levels of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Iloperidone is a time-dependent CYP3A inhibitor and may lead to increased plasma levels of drugs predominantly eliminated by CYP3A4.

              • indinavir

                indinavir will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                indinavir will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • isoniazid

                isoniazid will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • istradefylline

                istradefylline will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Istradefylline 40 mg/day increased peak levels and AUC of CYP3A4 substrates in clinical trials. This effect was not observed with istradefylline 20 mg/day. Consider dose reduction of sensitive CYP3A4 substrates.

              • itraconazole

                itraconazole will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • ivacaftor

                ivacaftor increases levels of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Ivacaftor and its M1 metabolite has the potential to inhibit P-gp; may significantly increase systemic exposure to sensitive P-gp substrates with a narrow therapeutic index.

              • ketoconazole

                ketoconazole will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                ketoconazole will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • lapatinib

                lapatinib will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                lapatinib will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • lemborexant

                etoposide will increase the level or effect of lemborexant by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Lower nightly dose of lemborexant recommended if coadministered with weak CYP3A4 inhibitors. See drug monograph for specific dosage modification.

              • letermovir

                letermovir increases levels of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • lomitapide

                etoposide increases levels of lomitapide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Lomitapide dose should not exceed 30 mg/day.

                lomitapide increases levels of etoposide by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Consider reducing dose when used concomitantly with lomitapide.

              • lonafarnib

                lonafarnib will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Modify Therapy/Monitor Closely. Lonafarnib is a weak P-gp inhibitor. Monitor for adverse reactions if coadministered with P-gp substrates where minimal concentration changes may lead to serious or life-threatening toxicities. Reduce P-gp substrate dose if needed.

              • lopinavir

                lopinavir will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • lorlatinib

                lorlatinib will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • meningococcal group B vaccine

                etoposide decreases effects of meningococcal group B vaccine by pharmacodynamic antagonism. Use Caution/Monitor. Individuals with altered immunocompetence may have reduced immune responses to the vaccine.

              • midazolam intranasal

                etoposide will increase the level or effect of midazolam intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Coadministration of mild CYP3A4 inhibitors with midazolam intranasal may cause higher midazolam systemic exposure, which may prolong sedation.

              • mifepristone

                mifepristone will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • mitotane

                mitotane decreases levels of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Mitotane is a strong inducer of cytochrome P-4503A4; monitor when coadministered with CYP3A4 substrates for possible dosage adjustments.

              • nafcillin

                nafcillin will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • nefazodone

                nefazodone will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • nelfinavir

                nelfinavir will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • nevirapine

                nevirapine will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • nicardipine

                nicardipine will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • nilotinib

                nilotinib will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                nilotinib will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • ofatumumab SC

                ofatumumab SC, etoposide. Either increases effects of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Consider the risk of additive immune system effects when coadministering immunosuppressive therapies with coadministration. When switching from therapies with immune effects, take into account the duration and mechanism of action of these therapies when initiating ofatumumab SC.

              • olaparib

                etoposide and olaparib both increase pharmacodynamic synergism. Use Caution/Monitor. Coadministration with other other myelosuppressive anticancer agents, including DNA damaging agents, may potentiate and prolongate the myelosuppressive toxicity.

              • oxcarbazepine

                oxcarbazepine will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • pentobarbital

                pentobarbital will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • phenobarbital

                phenobarbital will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • phenytoin

                phenytoin will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • ponatinib

                ponatinib increases levels of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • posaconazole

                posaconazole will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • primidone

                primidone will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • quinidine

                quinidine will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • ranolazine

                ranolazine will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • ribociclib

                ribociclib will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • rifabutin

                rifabutin will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • rifampin

                rifampin will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                rifampin will decrease the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • rifapentine

                rifapentine will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • ritonavir

                ritonavir will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                ritonavir will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • rucaparib

                rucaparib will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Adjust dosage of CYP3A4 substrates, if clinically indicated.

              • secobarbital

                secobarbital will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • siponimod

                siponimod and etoposide both increase immunosuppressive effects; risk of infection. Use Caution/Monitor. Caution if coadministered because of additive immunosuppressive effects during such therapy and in the weeks following administration. When switching from drugs with prolonged immune effects, consider the half-life and mode of action of these drugs to avoid unintended additive immunosuppressive effects.

              • sipuleucel-T

                etoposide decreases effects of sipuleucel-T by pharmacodynamic antagonism. Modify Therapy/Monitor Closely.

              • St John's Wort

                St John's Wort will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                St John's Wort will decrease the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • stiripentol

                stiripentol, etoposide. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Stiripentol is a CYP3A4 inhibitor and inducer. Monitor CYP3A4 substrates coadministered with stiripentol for increased or decreased effects. CYP3A4 substrates may require dosage adjustment.

              • tacrolimus

                tacrolimus will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • tazemetostat

                tazemetostat will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

                etoposide will increase the level or effect of tazemetostat by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • tecovirimat

                tecovirimat will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Tecovirimat is a weak CYP3A4 inducer. Monitor sensitive CYP3A4 substrates for effectiveness if coadministered.

              • tinidazole

                etoposide will increase the level or effect of tinidazole by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              • trastuzumab

                trastuzumab, etoposide. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Neutropenia or febrile neutropenia incidence were increased when trastuzumab was coadministered with myelosuppressive chemotherapy. .

              • trastuzumab deruxtecan

                trastuzumab deruxtecan, etoposide. Either increases toxicity of the other by immunosuppressive effects; risk of infection. Use Caution/Monitor. Neutropenia or febrile neutropenia incidence were increased when trastuzumab was coadministered with myelosuppressive chemotherapy. .

              • trazodone

                trazodone will decrease the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • tucatinib

                tucatinib will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor. Consider reducing the dosage of P-gp substrates, where minimal concentration changes may lead to serious or life-threatening toxicities.

              • vemurafenib

                vemurafenib increases levels of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • verapamil

                verapamil will increase the level or effect of etoposide by P-glycoprotein (MDR1) efflux transporter. Use Caution/Monitor.

              • voriconazole

                voriconazole will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

              Minor (3)

              • artemether/lumefantrine

                artemether/lumefantrine will decrease the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

              • grapefruit

                grapefruit will increase the level or effect of etoposide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

              • ruxolitinib

                etoposide will increase the level or effect of ruxolitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

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              Adverse Effects

              >10%

              Leukopenia (60-91%)

              Nausea and Vomiting (30-40%)

              Thrombocytopenia (28-41%)

              Alopecia (20-90%)

              Anorexia (13%)

              Diarrhea (13%)

              Leukopenia (60-91%)

              Anemia (≤33%)

              1-10%

              Pancytopenia (7%)

              Stomatitis (6%)

              Hepatic toxicity (3%)

              Type 1 hypersensitivity (2%)

              Orthostatic hypotension (1-2%)

              Peripheral neuropathy (1-2%)

              Frequency Not Defined

              Malaise

              Shivering

              Asthenia

              Fever

              Mucous membrane inflammation

              Hyperuricemia

              Local soft tissue toxicity has been reported following extravasation; see section on IV information for extravasation management

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              Warnings

              Black Box Warnings

              The drug should be administered under the supervision of an experienced cancer chemotherapy physician

              Severe myelosuppression, which could result in bleeding and infection, may occur

              Contraindications

              Hypersensitivity to etoposide or teniposide

              Cautions

              Withhold further treatment if platelet <50,000/mm³ or ANC <500/mm³

              Use caution in hepatic impairment

              Do NOT inject rapidly (may cause hypotension); infuse over at least 30-60 min

              Injection site reactions may occur during administration; monitor closely

              Avoid pregnancy

              May result in oligospermia, azoospermia, and permanent loss of fertility; sperm counts have been reported to return to normal levels in some men, and in some cases has occurred several years after end of therapy; may damage spermatozoa and testicular tissue, resulting in possible genetic fetal abnormalities; males with female sexual partners of reproductive potential should use condoms during therapy and for at least 4 months after final dose

              May cause infertility in females of reproductive potential and result in amenorrhea; premature menopause can occur; recovery of menses and ovulation is related to age at treatment; advise females of reproductive potential to use effective contraception during treatment for at least 6 months after final dose

              Occurrence of acute leukemia with or without a preleukemic phase reported in rare instances in patients treated with etoposide alone or in association with other neoplastic agents; risk of development of preleukemic or leukemic syndrome unclear

              Prescriber must consider benefits versus risk of therapy; if severe reactions occur, dose should be reduced or discontinued and appropriate corrective measures taken; reinstitution of therapy should be carried out with caution, and with adequate consideration of further need for drug and alertness as to possible recurrence of toxicity

              Patients with low serum albumin may be at increased risk for etoposide associated toxicities

              Anaphylactic reaction manifested by chills, fever, tachycardia, bronchospasm, dyspnea, and hypotension reported; higher rates of anaphylactic-like reactions reported in children who received infusions of etoposide at concentrations higher than those recommended; the role that concentration of infusion (or rate of infusion) plays in development of anaphylactic-like reactions is uncertain; treatment is symptomatic; infusion should be terminated immediately, followed by administration of pressor agents, corticosteroids, antihistamines, or volume expanders at the discretion of the physician

              Reversible cases of acute renal failure reported with administration of high dose (2220 mg/m²) with total body irradiation used for hematopoietic stem cell transplantation; the formulation contains dextran 40, which has been associated with acute renal failure when administered in high doses

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              Pregnancy & Lactation

              Pregnancy: Based on animal data and its mechanism of action, etoposide can cause fetal harm when administered to a pregnant woman; etoposide, the active moiety of etoposide phosphate is teratogenic in mice and rats advise pregnant women of potential hazard to a fetus; advise women of childbearing potential to avoid becoming pregnant

              Advise females of reproductive potential to use effective contraception during treatment and for 6 months after final dose In females of reproductive potential, may cause infertility and result in amenorrhea; premature menopause can occur; recovery of menses and ovulation is related to age at treatment

              Lactation: There is no information regarding presence of etoposide in human milk or its effects on breastfed infant milk production; because of potential for serious adverse reactions in nursing infants, advise women not to breastfeed during treatment with etoposide

              Pregnancy Categories

              A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

              B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

              C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

              D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

              X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

              NA: Information not available.

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              Pharmacology

              Mechanism of Action

              Appears to inhibit or alter DNA replication, induces G2-phase arrest & preferentially kills cells in G2 & late S phases

              Pharmacokinetics

              Bioavailability: 25-75%

              Protein bound: 94-98%

              Vd: 7-17 L/m²

              Metabolism: Liver

              Half-Life: 4-11 hr

              Peak plasma time: 1 hr

              Peak plasma concentration: 4.7 mcg/mL

              Clearance: 13.4 mL/min

              Excretion: Urine (35%)

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              Administration

              IV Incompatibilities

              Etoposide

              • Y-site: cefepime, filgrastim, idarubicin

              Etoposide PO4

              • Y-site: amphotericin B, cefepime, chlorpromazine, imipenem-cilastatin, methylprednisolone, mitomycin, prochlorperazine

              IV Compatibilities

              Etoposide

              • Additive: carboplatin, cisplatin, cisplatin/cyclophosphamide, cytarabine/daunorubicin, doxorubicin/vincristine (may lose some compatibility at high concentration of all 3 drugs), floxuridine, fluorouracil, hydroxyzine, ifosfamide, mitoxantrone, ondansetron
              • Y-site: allopurinol, amifostine, aztreonam, cladribine, doxorubicin liposomal, fludarabine, melphalan, methotrexate, mitoxantrone, ondansetron, paclitaxel, piperacillin-tazobactam, sargramostim, NaHCO3, teniposide, thiotepa, topotecan, vinorelbine

              Etoposide PO4

              • Additive: doxorubicin/vincristine
              • Y-site (partial list): acyclovir, amikacin, ampicillin, ampicilin-sulbactam, most cephalosporins (except cefepime), cisplatin, ciprofloxacin, clindamycin, cytarabine, cyclophosphamide, dactinomycin, daunorubicin, diphenhydramine, dobutamine, dopamine, doxorubicin, droperidol, fluconazole, fluorouracil, furosemide, heparin, idarubicin, linezolid, MgSO4, methotrexate, metoclopramide, mitoxantrone, morphine, ondansetron, paclitaxel, KCl, NaHCO3, vancomycin, vinblastine, vincristine, zidovudine

              IV Preparation

              VePesid, Toposar & equivalents

              • Concs >0.4 mg/mL are very unstable
              • Lower dose regimens (<1 g/dose): doses may be diluted in 100-1000 mL of D5W or NS
              • High dose regimens (>1 g/dose): draw total dose into an empty Viaflex container and add appropriate amount of diluent for a final concentration of 1 mg/mL
              • High dose, 2-Channel Pump Method
                • Instill all of the etoposide dose into one Viaflex container for a concentration of 20 mg/mL
                • Infuse this into one channel (any 2-channel infusion pump that does not require a hard plastic cassette)
                • Infuse indicated diluent (D5W or NS) at least 20x infusion rate of etoposide to simulate a 1 mg/mL concentration in the line
                • Etoposide should be Y-sited into the port most proximal to patient
                • Attach 0.22 micron filter to line after Y-site and before entry into patient

              Etopophos

              • Reconstitute to 10-20 mg/mL with any one of: D5W; NS; SWI; BWI; bacteriostatic NS
              • May be further diluted down to 0.1 mg/mL with NS or D5W

              IV Administration

              VePesid, Toposar & equivalents

              • Administer lower doses IVPB over at least 30 min to minimize the risk of hypotensive reactions
              • Administer high doses via 2-channel pump method; in-line 0.22 micron filter should be attached to ALL etoposide infusions due to the high potential for precipitation
              • Monitor for crystallization

              Etopophos

              • Infuse over 5-210 min

              Extravasation Management

              Treatment necessary only if large amount of conc soln extravasates

              Terminate injection or infusion immediately and aspirate back as much as possible

              Apply warm pack for 15-20 min QID and elevate

              May cause phlebitis, urticaria or redness

              Storage

              Store intact vials at room temp and protected from light

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              Images

              BRAND FORM. UNIT PRICE PILL IMAGE
              Toposar intravenous
              -
              20 mg/mL vial
              Toposar intravenous
              -
              20 mg/mL vial
              Toposar intravenous
              -
              20 mg/mL vial
              etoposide intravenous
              -
              20 mg/mL vial
              etoposide intravenous
              -
              20 mg/mL vial
              etoposide intravenous
              -
              20 mg/mL vial
              etoposide intravenous
              -
              20 mg/mL vial
              etoposide intravenous
              -
              20 mg/mL vial
              etoposide intravenous
              -
              20 mg/mL vial
              etoposide intravenous
              -
              20 mg/mL vial
              etoposide intravenous
              -
              20 mg/mL vial
              etoposide intravenous
              -
              20 mg/mL vial
              etoposide oral
              -
              50 mg capsule

              Copyright © 2010 First DataBank, Inc.

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              Patient Handout

              Select a drug:
              Patient Education
              etoposide intravenous

              ETOPOSIDE - INJECTION

              (e-TOE-poe-side)

              COMMON BRAND NAME(S): Toposar

              WARNING: This medication may cause certain severe blood and bone marrow problems (low red blood cells/white blood cells/platelets). This can affect your body's ability to stop bleeding or fight infection. Tell your doctor right away if you develop unusual tiredness, signs of infection (such as fever, chills, persistent sore throat), or easy bruising/bleeding (such as black stools, bloody vomit).

              USES: Etoposide is used to treat testicular cancer and certain forms of lung cancer (such as small cell lung cancer). Etoposide works by slowing the growth of cancer cells.

              HOW TO USE: This medication is given by slow injection into a vein by a health care professional. It is given as directed by your doctor, usually over 30 to 60 minutes every day or every other day for a total of 3 to 5 doses. This cycle may be repeated every 3 to 4 weeks.This medication may cause low blood pressure. Tell your doctor or other health care professional if you feel dizzy. Your injection may need to be stopped or given more slowly.The dosage is based on your medical condition, body size, and response to treatment. Your doctor will check your blood counts to make sure you can receive your next cycle. Keep all regular medical and laboratory appointments.

              SIDE EFFECTS: See also Warning and How to Use sections.Nausea, vomiting, diarrhea, dizziness, tiredness, weakness, changes in taste, loss of appetite, and pain/redness at the injection site may occur. Nausea and vomiting can be severe. In some cases, your doctor may prescribe medication to prevent or relieve nausea and vomiting. Eating several small meals, not eating before treatment, or limiting activity may help lessen some of these effects. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.Temporary hair loss may occur. Normal hair growth should return after treatment has ended.Pain or sores in the mouth and throat may occur. Brush your teeth carefully/gently, avoid using mouthwash that contains alcohol, and rinse your mouth frequently with cool water mixed with baking soda or salt. It may also be best to eat soft, moist foods.Many people using this medication may have serious side effects. However, you have been prescribed this drug because your doctor has judged that the benefit to you is greater than the risk of side effects. Careful monitoring by your doctor may decrease your risk.Tell your doctor right away if you have any serious side effects, including: numbness/tingling of arms/legs, sudden vision changes, eye pain, stomach/abdominal pain, yellowing eyes/skin, dark urine, painful/difficult swallowing, redness/swelling of your veins.This medication may lower your ability to fight infections. This may make you more likely to get a serious (rarely fatal) infection or make any infection you have worse. Tell your doctor right away if you have any signs of infection (such as fever, chills, persistent sore throat, cough).Although etoposide may be used to treat certain leukemias, it may rarely cause acute leukemia. Ask your doctor for more details.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing, fast heartbeat, seizures.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

              PRECAUTIONS: Before using etoposide, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: blood problems (such as low red blood cells/white blood cells/platelets), liver disease, kidney disease, previous radiation/chemotherapy treatment, heart problems.Etoposide can make you more likely to get infections or may worsen any current infections. Avoid contact with people who have infections that may spread to others (such as chickenpox, measles, flu). Consult your doctor if you have been exposed to an infection or for more details.Do not have immunizations/vaccinations without the consent of your doctor. Avoid contact with people who have recently received live vaccines (such as flu vaccine inhaled through the nose).To lower the chance of getting cut, bruised, or injured, use caution with sharp objects like razors and nail cutters, and avoid activities such as contact sports.This drug may make you dizzy. Alcohol or marijuana (cannabis) can make you more dizzy. Do not drive, use machinery, or do anything that needs alertness until you can do it safely. Limit alcoholic beverages. Talk to your doctor if you are using marijuana (cannabis).Daily use of alcohol while using this medicine may increase your risk for stomach bleeding. Ask your doctor or pharmacist about how much alcohol you may safely drink.Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).Children may be more sensitive to the side effects of this drug, especially allergic effects.Older adults may be more sensitive to the side effects of this drug, especially drowsiness, weakness, mouth/throat sores, loss of appetite, low white blood cells, and dehydration.This medication can affect fertility in both males and females. Ask your doctor for more details.Tell your doctor if you are pregnant or plan to become pregnant. You should not become pregnant while using etoposide. Etoposide may harm an unborn baby. Women should ask about reliable forms of birth control while using this medication and for 6 months after stopping treatment. Men should ask about reliable forms of birth control while using this medication and for 4 months after stopping treatment. If you or your partner becomes pregnant, talk to your doctor right away about the risks and benefits of this medication.This medication passes into breast milk. Because of the possible risk to the infant, breast-feeding while using etoposide is not recommended. Consult your doctor before breast-feeding.

              DRUG INTERACTIONS: Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.

              OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.

              NOTES: Laboratory and/or medical tests (such as complete blood count, kidney/liver function) should be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.

              MISSED DOSE: It is important to get each dose of this medication as scheduled. If you miss a dose, ask your doctor or pharmacist right away for a new dosing schedule.

              STORAGE: Consult the product instructions and your pharmacist for storage details. Keep all medications away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

              MEDICAL ALERT: Your condition can cause complications in a medical emergency. For information about enrolling in MedicAlert, call 1-888-633-4298 (US) or 1-800-668-1507 (Canada).

              Information last revised September 2021. Copyright(c) 2021 First Databank, Inc.

              IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

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              Formulary

              FormularyPatient Discounts

              Adding plans allows you to compare formulary status to other drugs in the same class.

              To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

              Adding plans allows you to:

              • View the formulary and any restrictions for each plan.
              • Manage and view all your plans together – even plans in different states.
              • Compare formulary status to other drugs in the same class.
              • Access your plan list on any device – mobile or desktop.

              The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

              Tier Description
              1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
              2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
              3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
              4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              NC NOT COVERED – Drugs that are not covered by the plan.
              Code Definition
              PA Prior Authorization
              Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
              QL Quantity Limits
              Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
              ST Step Therapy
              Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
              OR Other Restrictions
              Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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              Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.