dox-i-SYE-kleen

Therapeutic Classification: anti-infectives

Pharmacologic Classification: tetracyclines

• Treatment of various infections caused by unusual organisms, including:
  • Mycoplasma,
  • Chlamydia,
  • Rickettsia,
  • Borellia burgdorferi.
• Treatment of inhalational anthrax (postexposure) and cutaneous anthrax.
• Treatment of gonorrhea and syphilis in penicillin-allergic patients.
• Prevention of exacerbations of chronic bronchitis.
• Treatment of acne.
• Treatment of inflammatory lesions associated with rosacea (Oracea only).
• Malaria prophylaxis.

• Inhibits bacterial protein synthesis at the level of the 30S bacterial ribosome.
• Low-dose products used in the management of periodontitis inhibit collagenase.

• Bacteriostatic action against susceptible bacteria.

Spectrum:

• Includes activity against some gram-positive pathogens:
  • Bacillus anthracis(anthrax),
  • Clostridium perfringens,
  • Clostridium tetani,
  • Listeria monocytogenes,
  • Nocardia,
  • Propionibacterium acnes,
  • Actinomyces israelii.
• Active against some gram-negative pathogens:
  • Haemophilus influenzae,
  • Legionella pneumophila,
  • Yersinia enterocolitica,
  • Yersinia pestis,
  • Neisseria gonorrhoeae,
  • Neisseria meningitidis.
• Also active against several other pathogens, including:
  • Mycoplasma,
  • Treponema pallidum,
  • Chlamydia,
  • Rickettsia,
  • Borrelia burgdorferi.

Absorption: Well absorbed from the GI tract.

Distribution: Widely distributed, some CSF and good bone penetration.

Metabolism/Excretion: 20–40% excreted unchanged in urine; some inactivation in intestine and some enterohepatic circulation with excretion in bile and feces.

Half-life: 14–17 hr (↑ in severe renal impairment).

(plasma concentrations)

Contraindicated in:

• Hypersensitivity
• Some products contain alcohol or bisulfites and should be avoided in patients with known hypersensitivity or intolerance
• OB: Pregnancy — risk of bone growth inhibition and permanent staining of teeth in infant if used during 2nd or 3rd trimesters (may be used to treat anthrax in pregnant women due to the seriousness of the disease)
• Lactation: Lactation.

Use Cautiously in:

• Women of reproductive potential (↑ risk of intracranial hypertension if overweight or have a previous history of intracranial hypertension)
• Pedi: Children <8 yr (may cause permanent staining of teeth) (may be used to treat anthrax or Rocky Mountain spotted fever in children <8 yr due to the seriousness of these diseases).

Derm: photosensitivity, DRUG RASH WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), ERYTHEMA MULTIFORME, EXFOLIATIVE DERMATITIS, rash, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS.

GI: diarrhea, nausea, vomiting, CLOSTRIDIOIDES DIFFICILE-ASSOCIATED DIARRHEA (CDAD), dysphagia, esophagitis, glossitis, HEPATOTOXICITY, PANCREATITIS.

Hemat: blood dyscrasias.

Local: phlebitis at IV site.

Neuro: headache, intracranial hypertension.
Misc: hypersensitivity reactions, superinfection.

Drug-Drug:

• May ↑ effect of warfarin.
• May ↓ effectiveness of estrogen-containing oral contraceptives.
• Antacids, calcium, iron, and magnesium form insoluble compounds (chelates) and ↓ absorption of tetracyclines; this effect is least with doxycycline.
• Cholestyramine or colestipol↓ absorption of tetracyclines.
• Adsorbent antidiarrheals may ↓ absorption.
• Barbiturates, carbamazepine, or phenytoin may ↓ effectiveness.
• Isotretinoin may ↑ risk of intracranial hypertension; avoid concomitant use.

Drug-Food:

• Calcium in foods or dairy products↓ absorption by forming insoluble compounds (chelates); this effect is minimal with doxycycline.

More Common Infections

• PO (Adults and Children >8 yr and >45 kg): Most infections: 100 mg every 12 hr on the 1st day, then 100–200 mg once daily or 50–100 mg every 12 hr; Doryx MPC: 120 mg every 12 hr on the 1st day, then 120 mg once daily or 60 mg every 12 hr; Gonorrhea: 100 mg every 12 hr for 7 days or 200 mg once daily for 7 days (delayed-release tablets) or 300 mg followed 1 hr later by another 300-mg dose; Doryx MPC: 120 mg every 12 hr for 7 days or 360 mg followed 1 hr later by another 360–mg dose; Uncomplicated urethral, endocervical, or rectal infection caused by Chlamydia trachomatis: 100 mg every 12 hr for 7 days; Doryx MPC: 120 mg every 12 hr for 7 days; Syphilis (early): 100 mg every 12 hr for 14 days; Doryx MPC: 120 mg every 12 hr for 14 days; Syphilis (>1 yr duration): 100 mg every 12 hr for 4 wk; Doryx MPC: 120 mg every 12 hr for 4 wk; Malaria prophylaxis: 100 mg once daily (2 mg/kg once daily for children > 8 yr); Doryx MPC: 120 mg once daily; Lyme disease: 100 mg twice daily; Periodontitis–20 mg twice daily; Rosacea: 40 mg once daily in morning.
• PO (Children >8 yr and <45 kg): Less severe infections: 2.2 mg/kg every 12 hr on the 1st day, then 2.2–4.4 mg/kg once daily or 1.1–2.2 mg/kg every 12 hr; Doryx MPC: 2.6 mg every 12 hr on the 1st day, then 2.6 mg/kg once daily or 1.3 mg/kg every 12 hr.
• PO (Children >45 kg): Severe or life-threatening infections (Rocky Mountain Spotted Fever): 100 mg every 12 hr; Doryx MPC: 120 mg every 12 hr.
• PO (Children <45 kg): Severe or life-threatening infections (Rocky Mountain Spotted Fever): 2.2 mg/kg every 12 hr; Doryx MPC: 2.6 mg/kg every 12 hr.

Inhalational Anthrax (Postexposure)

• PO, IV (Adults and Children >45 kg): 100 mg IV every 12 hr; change to 100 mg PO every 12 hr when clinically appropriate for a total of 60 days; one or two other anti-infectives may be added initially, depending on clinical situation; Doryx MPC: 120 mg PO every 12 hr for 60 days.
• PO, IV (Children 45 kg): 2.2 mg/kg IV every 12 hr; change to 2.2 mg/kg PO every 12 hr when clinically appropriate for a total of 60 days; one or two other anti-infectives may be added initially, depending on clinical situation; Doryx MPC: 2.6 mg/kg PO every 12 hr for 60 days.

Cutaneous anthrax

• PO (Adults): 100 mg every 12 hr for 60 days; some patients may require IV therapy initially depending on clinical situation.
• PO (Children >8 yr and >45 kg): 100 mg every 12 hr; some patients may require IV therapy initially depending on clinical situation.
• PO (Children >8 yr and 45 kg): 2.2 mg/kg every 12 hr; some patients may require IV therapy initially depending on clinical situation.
• PO (Children 8 yr): 2.2 mg/kg every 12 hr; some patients may require IV therapy initially depending on clinical situation.

(Generic available)

• Immediate-release tablets: 20 mg; 50 mg; 75 mg; 100 mg; 150 mg;
• Immediate-release capsules: 50 mg; 75 mg; 100 mg; 150 mg;
• Delayed-release capsules (Oracea): 40 mg;
• Delayed-release tablets: 50 mg; 75 mg; 100 mg; 150 mg; 200 mg;
• Delayed-release tablets (Doryx MPC): 120 mg;
• Oral suspension (raspberry flavor): 25 mg/5 mL;
• Oral syrup (raspberry-apple flavor): 50 mg/5 mL;
• Powder for injection: 100 mg/vial;

• Infection: Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy.
  • Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results.
• Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of CDAD. May begin up to several wk following cessation of therapy.
• Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome or toxic epidermal necrolysis. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia.
• IV: Assess IV site frequently; may cause thrombophlebitis.

• Monitor renal and hepatic functions and CBC periodically during long-term therapy.
  • May cause ↑ AST, ALT, serum alkaline phosphatase, bilirubin, and amylase concentrations.
  • May cause false ↑ in urinary catecholamine levels.

• Do not confuse Oracea with Orencia.
  • May cause yellow-brown discoloration and softening of teeth and bones if administered prenatally or during early childhood. Not recommended for children under 8 yr of age or during pregnancy or lactation, unless used for the treatment of anthrax.
  • The Oracea product is only indicated for rosacea, not for infections.
• PO: Administer around the clock, at least 1 hr before or 2 hr after meals. May be taken with food or milk if GI irritation occurs. Administer with a full glass of liquid and at least 1 hr before going to bed to avoid esophageal ulceration. Use calibrated measuring device for liquid preparations. Shake liquid preparations well. Do not administer within 1–3 hr of other medications.
  • Capsules may also be administered by carefully opening and sprinkling capsule contents on a spoonful of applesauce. The applesauce should be swallowed immediately without chewing and followed with a cool 8-oz glass of water to ensure complete swallowing of the capsule contents. The applesauce should not be hot, and it should be soft enough to be swallowed without chewing. If mixture cannot be taken immediately, discard; do not stored for later use.
  • DNC: Do not open, break, crush or chew extended release capsules and tablets.
  • To prepare doses for infants and children exposed to anthrax (used only in a Declared Public Health Emergency): place one 100 mg tablet in a small bowl and crush to a fine powder with a metal spoon, leaving no large pieces. Add 4 level tsp of lowfat milk, lowfat chocolate milk, regular chocolate milk, chocolate pudding or an apple juice and sugar mixture made by combining 4 teaspoons of sugar and 4 teaspoons of apple juice. Mix food or drink and doxycycline powder until powder dissolves. Mixture is stable in a covered container for 24 hrs if refrigerated (if made with milk or pudding) or at room temperature (if made with juice). Number of teaspoons to administer/dose is based on child's weight (0–12.5 lbs — 1/2 tsp; 12.5–25 lbs — 1 tsp; 25–37.5 lbs — 1.5 tsp; 37.5–50 lbs — 2 tsp; 50–62.5 lbs — 2.5 tsp; 62.5–75 lbs — 3 tsp; 75–87.5 lbs — 3.5 tsp; 87.5–100 lbs — 4 tsp).
  • Avoid administration of calcium, antacids, magnesium-containing medications, sodium bicarbonate, or iron supplements within 1–3 hr of oral doxycycline.

IV Administration:

• Intermittent Infusion: Reconstitution: Reconstitute each 100 mg with 10 mL of sterile water or 0.9% NaCl for injection. Dilute further in 100–1000 mL of 0.9% NaCl, D5W, D5/LR, Ringer’s, or lactated Ringer’s solution. Solution is stable for 12 hr at room temperature and 72 hr if refrigerated. If diluted with D5/LR or lactated Ringer’s solution, administer within 6 hr. Protect solution from direct sunlight. Concentrations of less than 1 mcg/mL or greater than 1 mg/mL are not recommended.
• Rate: Administer over a minimum of 1–4 hr. Avoid rapid administration. Avoid extravasation.
• Y-Site Compatibility:
  • acyclovir
  • alemtuzumab
  • amifostine
  • amikacin
  • aminophylline
  • amiodarone
  • anidulafungin
  • argatroban
  • arsenic trioxide
  • ascorbic acid
  • atropine
  • azithromycin
  • aztreonam
  • benztropine
  • bivalirudin
  • bleomycin
  • bumetanide
  • buprenorphine
  • butorphanol
  • calcium chloride
  • calcium gluconate
  • cangrelor
  • carboplatin
  • carmustine
  • caspofungin
  • cefotaxime
  • ceftolozane/tazobactam
  • ceftriaxone
  • chlorpromazine
  • cisatracurium
  • cisplatin
  • clindamycin
  • cyanocobalamin
  • cyclophosphamide
  • cyclosporine
  • cytarabine
  • dacarbazine
  • dactinomycin
  • daptomycin
  • daunorubicin hydrochloride
  • dexmedetomidine
  • dexrazoxane
  • digoxin
  • diltiazem
  • diphenhydramine
  • dobutamine
  • docetaxel
  • dopamine
  • doxorubicin hydrochloride
  • enalaprilat
  • ephedrine
  • epinephrine
  • epirubicin
  • epoetin alfa
  • eptifibatide
  • ertapenem
  • esmolol
  • etoposide
  • etoposide phosphate
  • famotidine
  • fentanyl
  • filgrastim
  • fluconazole
  • fludarabine
  • fosphenytoin
  • gemcitabine
  • gentamicin
  • glycopyrrolate
  • granisetron
  • hetastarch
  • hydromorphone
  • idarubicin
  • ifosfamide
  • imipenem/cilastatin
  • insulin, regular
  • irinotecan
  • isavuconazonium
  • isoproterenol
  • labetalol
  • LR
  • leucovorin calcium
  • levofloxacin
  • lidocaine
  • linezolid
  • lorazepam
  • magnesium sulfate
  • mannitol
  • melphalan
  • meperidine
  • meropenem/vaborbactam
  • mesna
  • metoclopramide
  • metoprolol
  • metronidazole
  • midazolam
  • milrinone
  • mitoxantrone
  • morphine
  • multivitamins
  • mycophenolate
  • nalbuphine
  • naloxone
  • nicardipine
  • nitroglycerin
  • nitroprusside
  • norepinephrine
  • octreotide
  • ondansetron
  • oxaliplatin
  • oxytocin
  • paclitaxel
  • pamidronate
  • pantoprazole
  • papaverine
  • pentamidine
  • phentolamine
  • phenylephrine
  • phytonadione
  • plazomicin
  • potassium chloride
  • procainamide
  • prochlorperazine
  • promethazine
  • propofol
  • propranolol
  • protamine
  • pyridoxine
  • remifentanil
  • rituximab
  • rocuronium
  • sargramostim
  • sodium acetate
  • succinylcholine
  • sufentanil
  • tacrolimus
  • telavancin
  • theophylline
  • thiamine
  • thiotepa
  • tirofiban
  • tobramycin
  • topotecan
  • trastuzumab
  • vancomycin
  • vasopressin
  • vecuronium
  • verapamil
  • vinblastine
  • vincristine
  • vinorelbine
  • voriconazole
  • zoledronic acid
• Y-Site Incompatibility:
  • allopurinol
  • aminocaproic acid
  • amphotericin B deoxycholate
  • amphotericin B lipid complex
  • amphotericin B liposomal
  • ampicillin
  • ampicillin/sulbactam
  • cefazolin
  • cefotetan
  • cefoxitin
  • ceftazidime
  • cefuroxime
  • chloramphenicol
  • dantrolene
  • dexamethasone
  • diazepam
  • diazoxide
  • erythromycin
  • fluorouracil
  • folic acid
  • furosemide
  • ganciclovir
  • gemtuzumab ozogamicin
  • heparin
  • hydrocortisone
  • indomethacin
  • ketorolac
  • methotrexate
  • methylprednisolone
  • mitomycin
  • nafcillin
  • oxacillin
  • palonosetron
  • pemetrexed
  • penicillin G
  • pentobarbital
  • phenobarbital
  • phenytoin
  • piperacillin/tazobactam
  • potassium acetate
  • sodium bicarbonate
  • trimethoprim/sulfamethoxazole
.

• Instruct patient to take medication around the clock and to finish the drug completely as directed, even if feeling better. Take missed doses as soon as possible unless it is almost time for next dose; do not double doses. Advise patient that sharing of this medication may be dangerous.
  • Advise patient to avoid taking antacids, calcium, magnesium-containing medications, sodium bicarbonate, and iron supplements within 1–3 hr of oral doxycycline.
  • Instruct patient to notify health care professional immediately if rash, diarrhea, abdominal cramping, fever, or bloody stools occur and not to treat with antidiarrheals without consulting health care professionals.
  • Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
  • Advise patient to report the signs of superinfection (black, furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) or intracranial hypertension (headache, blurred vision, diplopia, vision loss). Women who are overweight, of childbearing age or have a history of intracranial hypertension are at greater risk for developing doxycycline-associated intracranial hypertension. Skin rash, pruritus, and urticaria should also be reported.
  • Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications.
  • Instruct patient to notify health care professional of medication regimen before treatment or surgery.
  • Caution patient to discard outdated or decomposed doxycycline; they may be toxic.
  • Advise females of reproductive potential to use a nonhormonal method of contraception while taking tetracyclines and until next menstrual period. Advise patient to notify health care professional promptly if pregnancy is planned or suspected or if breastfeeding. May be used for short term. Consider developmental and health benefits of breastfeeding with the mother’s clinical need for doxycyline and any potential adverse effects on the breast fed child from doxycyline or from the underlying maternal condition.
  • Instruct patient to notify health care professional if symptoms do not improve within a few days for systemic preparations.
• Malaria Prophylaxis: Advise patient to avoid being bitten by mosquitoes by using protective measures, especially from dusk to dawn (staying in well-screened areas, using mosquito nets, covering the body with clothing, using an effective insect repellent). Doxycycline prophylaxis should begin 1–2 days before travel to the malarious area, continued daily while in the malarious area and after leaving the malarious area, should be continued for 4 more wk to avoid development of malaria. Do not exceed 4 mo.

• Resolution of the signs and symptoms of infection. Length of time for complete resolution depends on the organism and site of infection.
• Decrease in acne lesions.
• Treatment of inhalational anthrax (postexposure) or treatment of cutaneous anthrax.
• Prevention of malaria.
• Reduction in inflammatory lesions associated with rosacea.

Acticlate, Doryx, Doryx MPC, Doxy, Oracea, Vibramycin

Apprilon, Doxycin, Doxytab, Periostat