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Hydrocortisone (Topical)

Pronunciation

Pronunciation

(hye droe KOR ti sone)

Index Terms

  • A-hydroCort
  • Compound F
  • Cortisol
  • Hemorrhoidal HC
  • Hydrocortisone Acetate
  • Hydrocortisone Butyrate
  • Hydrocortisone Probutate
  • Hydrocortisone Valerate
  • Nutracort

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Cream, External, as acetate:

Hydrocortisone Max St: 1% (28.4 g)

MiCort-HC: 2.5% (4 g, 28.4 g) [contains butylparaben, cetostearyl alcohol, propylparaben]

Cream, External, as base:

Ala Cort: 1% (28.4 g, 85.2 g) [contains cetyl alcohol, propylene glycol]

Anti-Itch Maximum Strength: 1% (28 g) [contains cetyl alcohol, methylparaben]

Anti-Itch Maximum Strength: 1% (28 g) [contains cetyl alcohol, methylparaben, propylene glycol, propylparaben]

Cortaid Maximum Strength: 1% (14 g, 28 g) [contains cetyl alcohol, disodium edta, ethylparaben, methylparaben, propylparaben]

Hydrocortisone Max St/12 Moist: 1% (28.4 g) [contains cetearyl alcohol, methylparaben, propylene glycol, propylparaben]

HydroSKIN: 1% (28 g [DSC]) [contains benzyl alcohol]

HydroSKIN: 1% (28 g) [contains methylparaben, propylene glycol, propylparaben]

Instacort 5: 0.5% (28.4 g)

Med-Derm Hydrocortisone: 0.5% (30 g); 1% (30 g)

Medi-First Hydrocortisone: 1% (1 ea) [contains trolamine (triethanolamine)]

Preparation H Hydrocortisone: 1% (26 g)

Recort Plus: 1% (30 g)

Generic: 0.5% (15 g, 28.35 g, 28.4 g, 30 g [DSC]); 1% (1 g, 1.5 g, 14.2 g, 20 g, 28 g, 28.35 g, 28.4 g, 30 g, 120 g, 453.6 g, 454 g [DSC]); 2.5% (20 g, 28 g, 28.35 g, 30 g, 453.6 g)

Cream, Rectal, as base:

Anusol-HC: 2.5% (30 g)

Procto-Med HC: 2.5% (30 g) [contains cetearyl alcohol, methylparaben, propylene glycol, propylparaben]

Procto-Pak: 1% (28.4 g)

Proctocort: 1% (28.35 g) [contains cetyl alcohol, propylene glycol]

Proctocream HC: 2.5% (30 g [DSC]) [contains benzyl alcohol]

Proctosol HC: 2.5% (28.35 g)

Proctozone-HC: 2.5% (30 g)

Proctozone-HC: 2.5% (30 g) [contains cetearyl alcohol, methylparaben, propylene glycol, propylparaben]

Generic: 1% (28.4 g); 2.5% (30 g)

Cream, External, as butyrate:

Locoid: 0.1% (15 g [DSC], 45 g [DSC])

Locoid: 0.1% (15 g, 45 g) [contains butylparaben, propylparaben]

Locoid Lipocream: 0.1% (45 g, 60 g) [contains butylparaben, cetostearyl alcohol, propylparaben]

Generic: 0.1% (15 g, 45 g, 60 g)

Cream, External, as probutate:

Pandel: 0.1% (15 g, 45 g, 80 g) [contains butylparaben, methylparaben, propylene glycol]

Cream, External, as valerate:

Generic: 0.2% (15 g, 45 g, 60 g)

Enema, Rectal, as base:

Colocort: 100 mg/60 mL (60 mL)

Cortenema: 100 mg/60 mL (60 mL) [contains methylparaben, polysorbate 80]

Generic: 100 mg/60 mL (60 mL)

Foam, Rectal, as acetate:

Cortifoam: 10% [90 mg/applicatorful] (15 g) [contains cetyl alcohol, methylparaben, propylene glycol, propylparaben, trolamine (triethanolamine)]

Gel, External, as acetate:

CortAlo: 2% (43 g [DSC]) [contains benzyl alcohol, menthol, trolamine (triethanolamine)]

NuZon: 2% (43 g [DSC]) [contains menthol, trolamine (triethanolamine)]

Generic: 2% (43 g [DSC])

Gel, External, as base:

Corticool: 1% (42.53 g) [contains cremophor el, propylene glycol]

First-Hydrocortisone: 10% (60 g) [contains propylene glycol, simethicone]

Instacort 10: 1% (30 g)

Kit, External, as base:

Advanced Allergy Collection: 2.5% [contains cetyl alcohol, methylparaben, propylene glycol, propylparaben]

Dermasorb HC: 2% [contains menthol, methylparaben, propylene glycol, propylparaben]

Pediaderm HC: 2% [DSC] [contains benzalkonium chloride, cetyl alcohol, isopropyl alcohol, methylparaben, propylene glycol, propylparaben]

Scalacort DK: Hydrocortisone lotion 2% and Sal Acid 2% and sulfur 2% [contains benzalkonium chloride, isopropyl alcohol, methylparaben, propylene glycol, propylparaben, soybean lecithin]

Lotion, External, as acetate:

NuCort: 2% (60 g) [contains benzyl alcohol, cetyl alcohol, menthol, trolamine (triethanolamine)]

Lotion, External, as base:

Ala Scalp: 2% (29.6 mL) [contains benzalkonium chloride, isopropyl alcohol, propylene glycol]

Aquanil HC: 1% (120 mL)

Beta HC: 1% (60 mL)

Hydro Skin Maximum Strength: 1% (118 mL) [contains benzyl alcohol]

HydroSKIN: 1% (118 mL) [contains benzyl alcohol, cetyl alcohol, propylene glycol]

Rederm: 1% (120 mL)

Sarnol-HC: 1% (59 mL)

Scalacort: 2% (29.6 mL) [contains benzalkonium chloride, isopropyl alcohol, propylene glycol]

TheraCort: 1% (118 mL [DSC]) [contains methylparaben, propylene glycol, propylparaben, trolamine (triethanolamine)]

Generic: 1% (114 g); 2.5% (59 mL, 118 mL)

Lotion, External, as butyrate:

Locoid: 0.1% (59 mL, 118 mL) [contains butylparaben, cetostearyl alcohol, propylparaben]

Ointment, External, as base:

Hydrocortisone in Absorbase: 1% (110 g)

Generic: 0.5% (28.35 g, 30 g); 2.5% (20 g, 28.35 g, 453.6 g, 454 g); 1% (25 g, 28 g, 28.35 g, 28.4 g, 30 g, 110 g, 430 g, 453.6 g)

Ointment, External, as butyrate:

Locoid: 0.1% (15 g, 45 g)

Generic: 0.1% (15 g, 45 g)

Ointment, External, as valerate:

Westcort: 0.2% (15 g, 45 g, 60 g) [contains propylene glycol]

Generic: 0.2% (15 g, 45 g, 60 g)

Solution, External, as base:

Scalpicin Maximum Strength: 1% (44 mL) [contains disodium edta, menthol, propylene glycol]

Texacort: 2.5% (30 mL) [lipid free, paraben free; contains alcohol, usp]

Solution, External, as butyrate:

Locoid: 0.1% (60 mL) [contains isopropyl alcohol]

Generic: 0.1% (20 mL, 60 mL)

Suppository, Rectal, as acetate:

Anucort-HC: 25 mg (12 ea, 24 ea, 100 ea)

Anusol-HC: 25 mg (12 ea, 24 ea)

GRx HiCort 25: 25 mg (12 ea [DSC])

Hemmorex-HC: 25 mg (12 ea, 24 ea); 30 mg (12 ea)

Hemril-30: 30 mg (12 ea [DSC], 24 ea [DSC])

Proctocort: 30 mg (12 ea)

Rectacort-HC: 25 mg (12 ea [DSC], 24 ea [DSC])

Generic: 25 mg (12 ea, 24 ea); 30 mg (12 ea)

Brand Names: U.S.

  • Advanced Allergy Collection
  • Ala Cort
  • Ala Scalp
  • Anti-Itch Maximum Strength [OTC]
  • Anucort-HC
  • Anusol-HC
  • Aquanil HC [OTC]
  • Beta HC [OTC]
  • Colocort
  • Cortaid Maximum Strength [OTC]
  • CortAlo [DSC]
  • Cortenema
  • Corticool [OTC]
  • Cortifoam
  • Dermasorb HC
  • First-Hydrocortisone
  • GRx HiCort 25 [DSC]
  • Hemmorex-HC
  • Hemril-30 [DSC]
  • Hydro Skin Maximum Strength [OTC]
  • Hydrocortisone in Absorbase
  • Hydrocortisone Max St [OTC]
  • Hydrocortisone Max St/12 Moist [OTC]
  • HydroSKIN [OTC]
  • Instacort 10 [OTC]
  • Instacort 5 [OTC]
  • Locoid
  • Locoid Lipocream
  • Med-Derm Hydrocortisone [OTC]
  • Medi-First Hydrocortisone [OTC]
  • MiCort-HC
  • NuCort
  • NuZon [DSC]
  • Pandel
  • Pediaderm HC [DSC]
  • Preparation H Hydrocortisone [OTC]
  • Procto-Med HC
  • Procto-Pak
  • Proctocort
  • Proctocream HC [DSC]
  • Proctosol HC
  • Proctozone-HC
  • Recort Plus [OTC]
  • Rectacort-HC [DSC]
  • Rederm [OTC]
  • Sarnol-HC [OTC]
  • Scalacort
  • Scalacort DK
  • Scalpicin Maximum Strength [OTC]
  • Texacort
  • TheraCort [OTC] [DSC]
  • Westcort

Pharmacologic Category

  • Antihemorrhoidal Agent
  • Corticosteroid, Rectal
  • Corticosteroid, Topical

Pharmacology

Topical corticosteroids have anti-inflammatory, antipruritic, and vasoconstrictive properties. May depress the formation, release, and activity of endogenous chemical mediators of inflammation (kinins, histamine, liposomal enzymes, prostaglandins) through the induction of phospholipase A2 inhibitory proteins (lipocortins) and sequential inhibition of the release of arachidonic acid. Hydrocortisone has low to intermediate range potency (dosage-form dependent).

Absorption

Topical corticosteroids are absorbed percutaneously. The extent is dependent on several factors, including epidermal integrity (intact vs abraded skin), formulation, and the use of occlusive dressings. Percutaneous absorption of topical steroids is increased in neonates (especially preterm neonates), infants, and young children. Rectal absorption is more substantial than most topical preparations; therefore, systemic effects are more common.

Metabolism

Hepatic

Excretion

Urine (major); bile

Use: Labeled Indications

Anal and genital itching (external): Use in postirradiation (factitial) proctitis, cryptitis, other inflammatory conditions of the anorectum; external genital, feminine, and anal itching.

Dermatoses: Relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses (eg, eczema; psoriasis; poison ivy, oak, or sumac; insect bites; minor skin irritation; atopic dermatitis [mild to moderate]; seborrheic dermatitis).

Hemorrhoids: Use in inflamed hemorrhoids.

Ulcerative colitis (adjunctive therapy): Adjunctive treatment of ulcerative colitis, especially distal forms including ulcerative proctitis, ulcerative proctosigmoiditis, left-sided ulcerative colitis, and in some cases involving the transverse and ascending colons.

Contraindications

Hypersensitivity to hydrocortisone or any component of the formulation; systemic fungal infections and ileocolostomy during the immediate or early postoperative period (rectal suspension); obstruction, abscess, perforation, peritonitis, fresh intestinal anastomoses, extensive fistulas, and sinus tracts (rectal foam).

OTC labeling: When used for self-medication, do not use for the treatment of diaper dermatitis.

Documentation of allergenic cross-reactivity for corticosteroids is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Dosing: Adult

Dermatosis: Topical:

Rx: Apply thin film to affected area 2 to 4 times daily.

Hydrocortisone butyrate (Locoid cream, Lipocream, ointment, solution): Apply thin film to affected area 2 to 3 times daily.

Hydrocortisone probutate (Pandel): Topical: Apply thin film to affected area 1 to 2 times daily.

Hydrocortisone valerate (Westcort): Topical: Apply thin film to affected area 2 to 3 times daily.

OTC: Apply thin film to the affected area up to 3 to 4 times daily.

Anal and genital itching, external: Topical: OTC labeling: Apply to affected area up to 3 to 4 times daily.

Hemorrhoids: Rectal: One suppository (25 or 30 mg) twice daily for 2 weeks. For severe cases of proctitis, 1 suppository 3 times daily or 2 suppositories twice daily may be needed. For factitial proctitis, duration of treatment may be up to 6 to 8 weeks.

Ulcerative colitis: Rectal:

Foam: One applicatorful (90 mg) 1 to 2 times daily for 2 to 3 weeks, and then every other day thereafter; use lowest dose to maintain clinical response; taper dose to discontinue long-term therapy

Suspension: One enema (100 mg) every night for 21 days or until remission (clinical improvement may precede improvement of mucosal integrity); 2 to 3 months of therapy may be required; to discontinue long-term therapy, gradually reduce administration to every other night for 2 or 3 weeks.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Atopic dermatitis: Topical: Infants ≥3 months, Children, and Adolescents: Hydrocortisone butyrate (Locoid Lipocream, Locoid lotion): Apply thin film to affected area twice daily.

Dermatosis: Topical:

Rx: Apply thin film to affected area 2 to 4 times daily.

Hydrocortisone butyrate (Locoid cream, Lipocream, ointment, solution): Apply thin film to affected area 2 to 3 times daily.

OTC: Apply thin film to the affected area up to 3 to 4 times daily. Products labeled for OTC use (self-medication) should not be used in children <2 years of age.

Anal and genital itching, external: Topical: Children ≥12 years and Adolescents: OTC labeling: Refer to adult dosing.

Dosing: Renal Impairment

There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Hepatic Impairment

There are no dosage adjustments provided in the manufacturer’s labeling.

Administration

Topical cream, lotion, ointment: Apply a thin film to clean, dry skin and rub in gently. Shake lotion well before use.

Rectal foam: Shake vigorously for 5-10 seconds prior to use. Do not remove cap during use. Hold container upright to fill applicator. Gently insert applicator tip into anus. Only use applicator provided by manufacturer; do not insert any part of the aerosol container in the anus. Clean applicator after each use with warm water.

Rectal suppository: Remove foil from rectal suppository and insert pointed end first. Avoid handling unwrapped suppository for too long.

Rectal suspension: Shake bottle well. Remove protective sheath from applicator tip. Lie on left side with left leg extended and right leg flexed forward. Gently insert lubricated applicator tip into rectum, pointed slightly toward navel. Grasp bottle firmly and squeeze slowly to instill the medication. After administering, withdraw and discard the used unit. Remain in position for at least 30 minutes. Retain the enema all night if possible.

Storage

Store at room temperature. Protect from heat and freezing.

Foam: Contents are under pressure; do not burn or puncture the container; do not store at temperatures above 48.9°C (120°F).

Drug Interactions

Aldesleukin: Corticosteroids may diminish the antineoplastic effect of Aldesleukin. Avoid combination

Ceritinib: Corticosteroids may enhance the hyperglycemic effect of Ceritinib. Monitor therapy

Corticorelin: Corticosteroids may diminish the therapeutic effect of Corticorelin. Specifically, the plasma ACTH response to corticorelin may be blunted by recent or current corticosteroid therapy. Monitor therapy

Deferasirox: Corticosteroids may enhance the adverse/toxic effect of Deferasirox. Specifically, the risk for GI ulceration/irritation or GI bleeding may be increased. Monitor therapy

Hyaluronidase: Corticosteroids may diminish the therapeutic effect of Hyaluronidase. Management: Patients receiving corticosteroids (particularly at larger doses) may not experience the desired clinical response to standard doses of hyaluronidase. Larger doses of hyaluronidase may be required. Consider therapy modification

Adverse Reactions

Frequency not defined. Local adverse events presented. Adverse events similar to those observed with systemic absorption are also observed, especially following rectal use. Refer to the Hydrocortisone (Systemic) monograph for details.

Cream, ointment: Dermatologic: Acneiform eruption, atrophic striae, burning sensation of skin, folliculitis, hypertrichosis, hypopigmentation, maceration of the skin, miliaria, perioral dermatitis, pruritus, secondary skin infection, skin atrophy, skin irritation, xeroderma

Enema:

Central nervous system: Localized burning

Hematologic & oncologic: Rectal hemorrhage

Local: Local pain

Suppositories:

Central nervous system: Localized burning

Dermatologic: Allergic contact dermatitis, folliculitis, hypopigmentation, pruritus, xeroderma

Infection: Secondary infection

Warnings/Precautions

Concerns related to adverse effects:

• Adrenal suppression: May cause hypercorticism or suppression of hypothalamic-pituitary-adrenal (HPA) axis, particularly in younger children or in patients receiving high doses for prolonged periods. HPA axis suppression may lead to adrenal crisis.

• Anaphylactoid reactions: Rare cases of anaphylactoid reactions have been observed in patients receiving corticosteroids.

• Contact dermatitis: Allergic contact dermatitis can occur and is usually diagnosed by failure to heal rather than clinical exacerbation; discontinue use if irritation occurs and treat appropriately.

• Immunosuppression: Prolonged use of corticosteroids may increase the incidence of secondary infection, mask acute infection (including fungal infections), prolong or exacerbate viral infections, or limit response to vaccines. Exposure to chickenpox or measles should be avoided; corticosteroids should not be used to treat ocular herpes simplex. Corticosteroids should not be used for cerebral malaria, fungal infections, or viral hepatitis. Close observation is required in patients with latent tuberculosis and/or tuberculosis reactivity; restrict use in active tuberculosis (only fulminating or disseminated tuberculosis in conjunction with antituberculosis treatment). Amebiasis should be ruled out in any patient with recent travel to tropical climates or unexplained diarrhea prior to initiation of corticosteroids.

• Kaposi sarcoma: Prolonged treatment with corticosteroids has been associated with the development of Kaposi sarcoma (case reports); if noted, discontinuation of therapy should be considered (Goedert 2002).

• Myopathy: Acute myopathy has been reported with high-dose corticosteroids, usually in patients with neuromuscular transmission disorders; may involve ocular and/or respiratory muscles; monitor creatine kinase; recovery may be delayed.

• Psychiatric disturbances: Corticosteroid use may cause psychiatric disturbances, including depression, euphoria, insomnia, mood swings, and personality changes. Preexisting psychiatric conditions may be exacerbated by corticosteroid use.

• Sensitization: Topical use has been associated with local sensitization (redness, irritation); discontinue if sensitization is noted.

• Systemic effects: Topical corticosteroids may be absorbed percutaneously. Absorption of topical corticosteroids may cause manifestations of Cushing syndrome, hyperglycemia, or glycosuria. Absorption is increased by the use of occlusive dressings, application to denuded skin, prolonged use, or application to large surface areas.

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with heart failure and/or hypertension.

• Diabetes: Use with caution in patients with diabetes mellitus.

• Gastrointestinal disease: Use with caution in patients with GI diseases (diverticulitis, intestinal anastomoses, peptic ulcer, nonspecific ulcerative colitis).

• Hepatic impairment: Use with caution in patients with hepatic impairment, including cirrhosis.

• Myasthenia gravis: Use with caution in patients with myasthenia gravis.

• Myocardial infarction: Use with caution following acute myocardial infarction (MI); corticosteroids have been associated with myocardial rupture.

• Ocular disease: Use with caution in patients with cataracts and/or glaucoma; increased intraocular pressure, glaucoma, and cataracts have occurred with prolonged use.

• Osteoporosis: Use with caution in patients with osteoporosis.

• Renal impairment: Use with caution in patients with renal impairment; fluid retention may occur.

• Thyroid disease: Use caution with thyroid disease. Changes in thyroid status may necessitate dosage adjustments; metabolic clearance of corticosteroids increases in hyperthyroid patients and decreases in hypothyroid ones.

• Ulcerative colitis: With severe ulcerative colitis, it may be hazardous to delay surgery while waiting for response to treatment.

Special populations:

• Elderly: Because of the risk of adverse effects associated with systemic absorption, topical corticosteroids should be used cautiously in elderly patients in the smallest possible effective dose for the shortest duration.

• Pediatric: Children may absorb proportionally larger amounts after topical application and may be more prone to systemic effects. HPA axis suppression, intracranial hypertension, and Cushing syndrome have been reported in children receiving topical corticosteroids. Prolonged use may affect growth velocity; growth should be routinely monitored in pediatric patients.

Dosage form specific issues:

• Appropriate use: Avoid use of topical preparations with occlusive dressings or on weeping or exudative lesions. Not for treatment of diaper dermatitis.

• Benzyl alcohol: Some dosage forms may contain benzyl alcohol and/or sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol and/or benzyl alcohol derivative with caution in neonates. See manufacturer’s labeling.

• Rectal enema: Damage to the rectal wall may occur from improper or careless insertion of the enema tip. Use with caution when there is a probability of impending perforation, abscess, or other pyogenic infection; obstruction; or extensive fistulas and sinus tracts.

• Rectal foam: Do not insert any part of the aerosol container directly into the anus. Contents are under pressure; do not burn or puncture the container; do not store at temperatures above 48.9°C (120°F). If there is not evidence of clinical or proctologic improvement within 2 or 3 weeks after initiation of therapy, or if the condition worsens, discontinue use. Contraindicated in obstruction, abscess, perforation, peritonitis, fresh intestinal anastomoses, extensive fistulas, and sinus tracts.

Other warnings/precautions:

• Discontinuation of therapy: After long-term use, withdraw therapy with gradual tapering of dose.

• Self-medication (OTC use): Contact health care provider if condition worsens, symptoms persist for >7 days, or rectal bleeding occurs.

• Stress: May require higher doses when subject to stress (ie, trauma, surgery, severe infection).

Monitoring Parameters

Serum glucose, electrolytes; blood pressure, weight, presence of infection; monitor IOP with therapy >6 weeks; bone mineral density, growth in children

Pregnancy Risk Factor

C

Pregnancy Considerations

Adverse events have been observed in animal reproduction studies. When topical corticosteroids are needed during pregnancy, low to mid potency preparations are preferred; higher potency preparations should be used for the shortest time possible and fetal growth should be monitored (Chi 2011; Chi 2013). Topical products are not recommended for extensive use, in large quantities, or for long periods of time in pregnant women (Leachman 2006).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience stinging, burning, dry skin, or rectal irritation. Have patient report immediately to prescriber signs of high blood sugar (confusion, feeling sleepy, more thirst, hunger, passing urine more often, flushing, fast breathing, or breath that smells like fruit), signs of adrenal gland problems (severe nausea, vomiting, severe dizziness, passing out, muscle weakness, severe fatigue, mood changes, lack of appetite, or weight loss), signs of Cushing’s disease (weight gain in upper back or stomach; moon face; severe headache; or slow healing), signs of skin changes (pimples, stretch marks, slow healing, or hair growth), vision changes, severe headache, skin irritation, severe rectal bleeding, or severe rectal pain (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

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