doxycycline (Rx)

Brand and Other Names:Vibramycin, Monodox, more...Acticlate, Atridox, Avidoxy, Doxy, Doxycin, Doryx, Oracea, Periostat, Adoxa, Ocudox, Doryx MPC
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

capsule

  • 50mg (Monodox, generic)
  • 75mg (Monodox)
  • 100mg (Monodox, Vibramycin, generic)
  • 150mg (Adoxa)

solution, reconstituted powder for IV

  • 100mg (Doxy, generic)

syrup

  • 50mg/5mL (Vibramycin)

oral suspension

  • 25mg/5mL (Vibramycin, generic)

tablet

  • 20mg (generic)
  • 50mg (Adoxa, generic)
  • 75mg (Acticlate, Adoxa, generic)
  • 100mg (Adoxa, generic)
  • 150mg (Acticlate, generic)

tablet, delayed-release

  • 50mg (Doryx)
  • 60mg (Doryx MPC)
  • 75mg (generic)
  • 100mg (generic)
  • 120mg (Doryx MPC)
  • 150mg (Doryx, generic)
  • 200mg (Doryx)

capsule, delayed-release

  • 40mg (Oracea, generic)

periodontal extended-release liquid

  • 10%

Rickettsial Infections

Rocky Mountain spotted fever, typhus fever and the typhus group, Q fever, rickettsialpox, and tick fevers caused by Rickettsiae

Initial: 200 mg/day divided twice daily PO/IV on first day (IV may be given qDay), THEN

Maintenance: 100-200 mg/day qDay or divided q12hr PO/IV (IV may be given qDay)

Sexually Transmitted Infections

Uncomplicated urethral, endocervical or rectal infections caused by Chlamydia trachomatis

Nongonococcal urethritis caused by Ureaplasma urealyticum

Lymphogranuloma venereum caused by Chlamydia trachomatis

Granuloma inguinale caused by Klebsiella granulomatis

Uncomplicated gonorrhea caused by Neisseria gonorrhoeae

Chancroid caused by Haemophilus ducreyi

Uncomplicated urethral, endocervical, or rectal infection caused by Chlamydia trachomatis: 100 mg PO BID for 7 days

Alternate dosing regimen for uncomplicated urethral or endocervical infection caused by Chlamydia trachomatis: 200 mg PO BID for 7 days

Uncomplicated gonococcal infections (except anorectal infections in men): 100 mg PO BID for 7 days

Alternate single visit dose: 300 mg stat followed in 1 hr by a second 300 mg dose

Nongonococcal urethritis (NGU) caused by U. urealyticum: 100 mg PO BID for 7 day

Respiratory Tract Infections

Respiratory tract infections caused by Mycoplasma pneumoniae

Psittacosis (ornithosis) caused by Chlamydophila psittaci

Indicated for respiratory tract infections caused by the following microorganisms, when bacteriological testing indicates appropriate susceptibility to drug: Haemophilus influenzae, Klebsiella species, Streptococcus pneumoniae

Initial: 200 mg/day divided twice daily PO/IV on first day (IV may be given qDay), THEN

Maintenance: 100-200 mg/day qDay or divided q12hr PO/IV (IV may be given qDay)

Specific Bacterial Infections

Relapsing fever due to Borrelia recurrentis

Plague due to Yersinia pestis

Tularemia due to Francisella tularensis

Cholera caused by Vibrio cholerae

Campylobacter fetus infections caused by Campylobacter fetus

Brucellosis due to Brucella species (in conjunction with streptomycin)

Bartonellosis due to Bartonella bacilliformis

Gram negative microorganisms (eg, Escherichia coli Enterobacter aerogenes, Shigella species, Acinetobacter species, urinary tract infections caused by Klebsiella species)

Initial: 200 mg/day divided twice daily PO/IV on first day (IV may be given qDay), THEN

Maintenance: 100-200 mg/day qDay or divided q12hr PO/IV (IV may be given qDay)

Ophthalmic infections

Trachoma caused by Chlamydia trachomatis, although the infectious agent is not always eliminated as judged by immunofluorescence

Inclusion conjunctivitis caused by Chlamydia trachomatis

Acute epididymo-orchitis caused by C. trachomatis: 100 mg, PO BID for at least 10 days

Anthrax

Anthrax due to Bacillus anthracis, including inhalational anthrax (postexposure)

100 mg PO BID for 60 days

Select Infections When Penicillin is Contraindicated

When penicillin is contraindicated, doxycycline is an alternative treatment of the following infections:

  • Syphilis caused by Treponema pallidum
  • Yaws caused by Treponema pallidum subspecies pertenue
  • Vincent’s infection caused by Fusobacterium fusiforme
  • Actinomycosis caused by Actinomyces israelii. Infections caused by Clostridium species
  • Syphilis (<1 year duration): 100 mg PO BID for 2 weeks
  • Syphilis (≥1 year duration): 100 mg PO BID for 4 weeks

Acute Intestinal Amebiasis and Severe Acne

Adjunctive therapy for acute intestinal amebiasis and severe acne

Initial: 200 mg/day divided twice daily PO/IV on first day (IV may be given qDay), THEN

Maintenance: 100-200 mg/day qDay or divided q12hr PO/IV (IV may be given qDay)

Malaria

Indicated for prophylaxis of malaria due to Plasmodium falciparum in short-term travelers (<4 months) to areas with chloroquine and/or pyrimethamine-sulfadoxine resistant strains

Prophylaxis: 100 mg PO qDay; begin taking 1-2 days before travel and continue daily during travel and for 4 weeks after traveler leaves malaria infested area

Severe infection (off-label): 100 mg PO/IV q12hr x 7 days with 3-7 days quinidine gluconate

Uncomplicated infection (off-label): 100 mg PO q12hr x 7 days with 3-7 days quinine sulfate depending on region

Equivalent dose of Doryx MPC is 120 mg

Periodontal Disease

Atridox: Apply subgingivally; dose depends on size, shape, and number of pockets treated

Dosing Considerations

Susceptible organisms

  • Propionibacterium acnes, Actinomyces israelii, Acinetobacter spp, Bacillus anthracis, Bacteroides spp., Bartonella bacilliformis, Bartonella henselae, Bartonella quintana, Borrelia recurrentis, Brucella spp, Campylobacter jejuni, Chlamydia psittaci, Chlamydia trachomatis, Capnocytophaga canimorsus, Citrobacter diversus, Citrobacter freundii, Escherichia coli, Eikenella corrodens, Francisella tularensis, Haemophilus ducreyi, Helicobacter pylori, Klebsiella granulomatis, Klebsiella pneumoniae, Listeria monocytogenes, Mycoplasma hominis, Mycoplasma pneumoniae, Neisseria gonorrhoeae, Propionibacterium acnes, Rickettsiae, Shigella spp., MRSA, Staphylococcus saprophyticus, Streptococcus spp, Treponema pallidum, Ureaplasma urealyticum, Vibrio cholerae, Yersinia enterocolitica, Yersinia pestis, VRE, mycobacteria other than tuberculosis

Dosage Forms & Strengths

capsule

  • 50mg (Monodox, generic)
  • 75mg (Monodox)
  • 100mg (Monodox, Vibramycin, generic)
  • 150mg (Adoxa)

solution, reconstituted powder for IV

  • 100mg (Doxy, generic)

syrup

  • 50mg/5mL (Vibramycin)

oral suspension

  • 25mg/5mL (Vibramycin, generic)

tablet

  • 20mg (generic)
  • 50mg (Adoxa, generic)
  • 75mg (Acticlate, Adoxa, generic)
  • 100mg (Adoxa, generic)
  • 150mg (Acticlate, generic)

tablet, delayed-release

  • 50mg (Doryx)
  • 60mg (Doryx MPC)
  • 75mg (generic)
  • 100mg (generic)
  • 120mg (Doryx MPC)
  • 150mg (Doryx, generic)
  • 200mg (Doryx)

capsule, delayed-release

  • 40mg (Oracea, generic)

General Dosing Guidelines

≤8 years: Not recommended for mild-to-moderate infections; may cause tooth discoloration and enamel hypoplasia during tooth development

>8 years, <45 Kg

  • Load: 4.4 mg/kg/day PO/IV divided q12hr day 1  
  • Maintenance: 2.2-4.4 mg/kg/day IV/PO qDay (may divide BID for higher doses)
  • Doryx MPC
    • Severe or life-threatening infections (eg, anthrax, Rocky Mountain spotted fever): 2.6 mg/kg PO BID
    • Less severe infections: 5.3 mg/kg PO divided into 2 doses on day 1, then a maintenance dose of 2.6 mg/kg PO qDay

>8 years, ≥45 kg

  • 100 mg PO q12hr or 50 mg PO q6hr on day 1, followed by maintenance dose of 100 mg/day as single dose or as 50 mg q12hr
  • Doryx MPC: 120 mg PO q12hr on day 1, followed by maintenance dose of 120 mg/day; may increase frequency to q12hr for more severe infections, particularly chronic UTI

Anthrax

Anthrax due to Bacillus anthracis, including inhalational anthrax (postexposure)

≤8 years: 2.2 mg/kg PO/IV q12hr for 60 days (change to amoxicillin as soon as penicillin susceptibility confirmed)  

>8 years

  • ≤45 kg: 2.2 mg/kg PO/IV q12hr for 60 days (Doryx MPC: 2.6 mg/kg PO q12hr for 60 days)
  • >45 kg: 100 mg PO/IV q12hr for 60 days (Doryx MPC: 120 mg PO q12hr for 60 days)

Malaria

Prophylaxis

  • Indicated for prophylaxis of malaria due to Plasmodium falciparum in short-termtravelers (<4 months) to areas with chloroquine and/or pyrimethamine-sulfadoxineresistant strains
  • 2 mg/kg PO qDay; not to exceed 100 mg /day
  • Doryx MPC: 2.4 mg/kg PO qDay
  • Initiate treatment 1-2 days prior to travel to endemic area and continue for 4 weeks after leaving the area

Severe infection

  • <45 kg: 2.2 mg/kg q12hr for 7 days with quinidine gluconate
  • ≥45 kg (Off label): 100 mg PO/IV q12hr for 7 days with quinidine gluconate

Uncomplicated

  • >8 years: 2.2 mg/kg; not to exceed 100 mg dose PO q12hr for 7 days with quinine sulfate

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Interactions

Interaction Checker

and doxycycline

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    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            Frequency Not Defined

            Anorexia

            Dental discoloration

            Diarrhea

            Dysphagia

            Enterocolitis

            Erythema multiform

            Esophageal ulcer

            Esophagitis

            Exacerbation of systemic lupus erythematosus

            Exfoliative dermatitis

            Glossitis

            Headache

            Hemolytic anemia

            Hepatotoxicity

            Hypoglycemia

            Inflammatory anogenital lesion

            Intracranial hypertension

            Nausea

            Neutropenia

            Pericarditis

            Serum sickness

            Skin hyperpigmentation

            Toxic epidermal necrolysis

            Thrombocytopenia

            Upper abdominal pain

            Urticaria

            Vomiting

            Drug rash with eosinophilia and systemic symptoms

            Postmarketing Reports

            Pancreatitis

            Stevens-Johnson syndrome

            Maculopapular and erythematous rashes

            Angioneurotic edema

            Anaphylaxis

            Anaphylactoid purpura

            Jarisch-Herxheimer reaction in the setting of spirochete infections

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            Warnings

            Contraindications

            Documented hypersensitivity

            Cautions

            Use of tetracyclines during tooth development (last half of pregnancy through age 8 years) can cause permanent discoloration of teeth; use doxycycline in pediatric patients 8 years of age or less only when potential benefits expected to outweigh risks in severe or life-threatening conditions (eg, anthrax, Rocky Mountain spotted fever); particularly when there are no alternative therapies

            Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, and may range in severity from mild diarrhea to fatal colitis

            Photosensitivity manifested by an exaggerated sunburn reaction has been observed in some individuals taking tetracyclines

            May result in overgrowth of non-susceptible organisms, including fungi. If such infections occur, discontinue use and institute appropriate therapy

            Severe skin reactions, such as exfoliative dermatitis, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug reaction with eosinophilia and systemic symptoms (DRESS) reported; if severe skin reactions occur, discontinue therapy immediately and institute appropriate therapy

            Intracranial hypertension (pseudotumor cerebri) reported (rare) may occur; symptoms include headache, blurred vision, diplopia, and vision loss; papilledema can be found on funduscopy; women of childbearing age who are overweight or have a history of IH are at greater risk; possibility for permanent visual loss exists; if visual disturbance occurs during treatment, prompt ophthalmologic evaluation is warranted; intracranial pressure can remain elevated for weeks after drug cessation; monitor until they stabilize

            All tetracyclines form a stable calcium complex in any bone-forming tissue; decrease in fibula growth rate has been observed in prematures given an oral tetracycline; reaction was shown to be reversible when the drug was discontinue

            Antianabolic action of the tetracyclines may cause an increase in BUN; studies to date indicate that this does not occur with the use of doxycycline in patients with impaired renal function

            Doxycycline offers substantial but not complete suppression of the asexual blood stages of Plasmodium strains

            Prescribing doxycycline in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria

            In long-term therapy, periodic laboratory evaluation of organ systems, including hematopoietic, perform renal and hepatic studies

            Drug interaction overview

            • Because tetracyclines have been shown to depress plasma prothrombin activity, patients who are on anticoagulant therapy may require downward adjustment of their anticoagulant dosage
            • Since bacteriostatic drugs may interfere with the bactericidal action of penicillin, it is advisable to avoid giving tetracyclines in conjunction with penicillin
            • Absorption of tetracyclines is impaired by antacids containing aluminum, calcium, or magnesium, bismuth subsalicylate, and iron-containing preparations
            • Concurrent use of tetracyclines, may render oral contraceptives less effective
            • Barbiturates, carbamazepine, and phenytoin decrease the half-life of doxycycline
            • Coadministration of tetracycline and methoxyflurane has been reported to result in fatal renal toxicity
            • False elevations of urinary catecholamines may occur due to interference with the fluorescence test
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            Pregnancy & Lactation

            Pregnancy

            Therapy may cause discoloration deciduous teeth, and reversible inhibition of bone growth when administered during second and third trimester of pregnancy

            Available data from published studies over decades have not shown a difference in major birth defect risk compared to unexposed pregnancies with doxycycline exposure in first trimester of pregnancy

            The vast majority of reported experience during human pregnancy is short-term, first trimester exposure; there are no human data available to assess effects of long-term therapy in pregnant women such as that proposed for treatment of anthrax exposure

            An expert review of published data on experiences with doxycycline use during pregnancy concluded that therapeutic doses during pregnancy are unlikely to pose substantial teratogenic risk (the quantity and quality of data were assessed as limited to fair), but the data are insufficient to state that there is no risk; there are no adequate and well-controlled studies on use of drug in pregnant women

            A small prospective study of 81 pregnancies describes 43 pregnant women treated for 10 days with doxycycline during early first trimester; all mothers reported their exposed infants were normal at 1 year of age

            There are no available data on risk of miscarriage following exposure to doxycycline in pregnancy; advise patient of potential risk to fetus if drug is used during pregnancy

            Based on findings from a fertility study in animals, doxycycline may impair female and male fertility; the reversibility of this finding is unclear

            Lactation

            Based on available published data, doxycycline is present in human milk; there are no data that inform about levels of doxycycline in breastmilk, effects on breastfed infant, or on milk production

            Short-term use by lactating women not necessarily contraindicated; effects of prolonged exposure to doxycycline in breast milk are unknown; because of potential for serious adverse reactions in nursing infants from drug, a decision should be made whether to discontinue nursing or to discontinue drug, taking into account importance of drug to mother

            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

            Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria; may block dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

            Absorption

            Oral: Almost complete; reduced 20% by food or milk

            Peak serum time: 1.5-4 hr

            Bioavailability: Reduced at high pH

            Distribution

            Protein bound: 90%

            Metabolism

            Liver

            Elimination

            Half-life: 15-25 hr

            Excretion: Urine (23%); feces (30%)

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            Administration

            Oral Administration

            Absorption decreased when taken with food, particularly food containing calcium

            Doryx MPC, delayed-release tablet

            • Do not substitute on a mg-per-mg basis with other oral doxycyclines because of differing bioavailability
            • Do not chew or crush tablets
            • The recommended dosage, frequency of administration, and weight-based dosage recommendations differ from that of other doxycyclines; exceed the recommended dose may increase incidence of adverse effects
            • Administer with adequate amount of fluid to was down the drug and reduce risk of esophageal irritation/ulceration
            • Switching from Doryx to Doryx MPC
              • Doryx MPC 60 mg replaces Doryx 50 mg
              • Doryx MPC 120 mg replaces Doryx 100 mg

            IV Incompatibilities

            Additive: Meropenem (comp at 1 g/L mero and 200 mg/L doxy; incomp at 20 g/L and 200 mg/L doxy)

            Y-site: Allopurinol, heparin, piperacillin/tazobactam

            IV Compatibilities

            Solution: D5W, NS

            Additive: Ranitidine

            Syringe: Doxapram

            Y-site (partial list): Acyclovir, amiodarone, aztreonam, hydromorphone, linezolid, MgSO4, meperidine, meropenem (comp at 1 mg/mL mero and 1 mg/mL doxy; incomp at 50 mg/mL mero and 1 mg/mL doxy), morphine SO4, propofol, remifentanil

            IV Preparation

            For IV infusion dilute to a final concentration of 0.1-1 mg/mL w/ NS, D5W, LR, or D5/LR

            IV Administration

            Administer by slow IV infusion, usually over 1-2 hr

            Use central line if possible

            Avoid rapid administration

            Other parenteral routes not recommended

            Periodontal Preparation (Atridox)

            If refrigerated, remove Atridox from refrigeration at least 15 minutes prior to mixing

            Inject liquid contents of Syringe A (indicated by red stripe) into Syringe B (doxycycline powder) and then push the contents back into Syringe A

            Complete 100 mixing cycles at a pace of 1 cycle per second using brisk strokes

            Subgingival Administration (Atridox)

            Does not require local anesthesia for subgingival placement

            If desired, using an appropriate dental instrument, may be packed into the pocket

            Dipping the edge of the instrument in water before packing will help keep Atridox from sticking to the instrument, and will help speed coagulation of Atridox

            A few drops of water dripped onto the surface of Atridox once in the pocket will also aid in coagulation; if necessary, add more Atridox as described above and pack it into the pocket until the pocket is full

            Storage

            Tablets or capsules: Store at 20-25ºC (68-77ºF) excursions permitted to 15-30ºC (59-86ºF); protect from light and moisture; dispense in a tight, light-resistant container

            Atridox: Store at 2-30ºC (36-86ºF)

            Vibramycin (all formulations): Store <30ºC (86ºF) and dispensed in tight, light-resistant containers

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            Formulary

            FormularyPatient Discounts

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            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.