Dispensing Dose Packs

 

A number of meds are available in dose packs.  These may be starter or titration packs (also called initiation or loading packs in Canada), where the med dose is gradually increased; they may contain a short course of therapy; or they may be tapering packs, where the med dose is gradually reduced.  Dose packs can be very convenient for patients.  For example, they can take the guesswork out of adhering to a regimen when the dose is changing frequently.  This may be the case when a dose must be increased slowly to reduce the risk of side effects, such as with milnacipran (Savella) or vilazodone (Viibryd), or when patients receive a higher dose to start then taper down to a lower dose, such as with methylprednisolone or certain blood thinners (apixaban [Eliquis], etc).  However, prescriptions for dose packs can be a challenge, especially if a pharmacy doesn’t stock particular packs.  Plus there are some errors that can come up with starter packs.  Use the following strategies to prevent errors with dose packs, and see our chart below for contents of commonly dispensed dose packs.1

 

  • Do a double check if you see that a dose pack Rx has a refill.  In many cases, this will not be appropriate.
  • Try to avoid filling an Rx for a starter pack and an Rx for a maintenance dose at the same time.  This can help prevent problems, such as the patient taking both doses at the same time.
  • Include clear instructions on the patient label when filling an Rx for a maintenance dose, such as by advising the patient not to start the maintenance dose until the starter pack has been completed.
  • Help ensure patients who get dose packs receive pharmacist counseling, so the pharmacist can provide details about taking the med.

 

Brand
 (Generic)

Type and Contents of Pack

 

Days’ Supply

Adlyxin2
 
(lixisenatide)

Starter pack (U.S. only):
10 mcg prefilled pen x 1;
20 mcg prefilled pen x 1

 

28 days

Alunbrig20,28
 
(brigatinib)

Initiation pack:
90 mg tablets x 7;
 180 mg tablets x 23 (U.S.) or 180 mg tablets x 21 (Canada)

 

30 days (U.S.)
 28 days (Canada)

Avelox4
 
(moxifloxacin)

 

 

ABC Pack (U.S. only):  400 mg tablets x 5

5 days

Chantix (U.S.)5
 
Champix (Canada)6
 
(varenicline)

Starting month PAK (first month):
0.5 mg tablets x 11 per card (1 card);
1 mg tablets x 14 per card (3 cards)
(Note that the Canadian product, called an initial dosing pack, has one card with 0.5 mg tablets x 11 and 1 mg tablets x 14, and a second card with 1 mg tablets x 28)
Continuing month PAK (continuing months):
 1 mg tablets x 14 per card (4 cards)

Starting month box (first month):
0.5 mg tablets x 11
1 mg tablets x 42
Continuing month box (continuing months):
 1 mg x 56 tablets

 

28 days
 (Starting month PAK or box [U.S.], Initial dosing pack [Canada])

Cimzia3
 
(certolizumab pegol)

Starter kit (U.S. only):
200 mg prefilled pen x 6

 

28 days

Eliquis7
 
(apixaban)

Starter pack for treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) (U.S. only):
5 mg tablets x 42 (1 blister pack)
 5 mg tablets x 32 (1 blister pack)

 

30 days

Emend30,31
 
(aprepitant)

Tri-Pack:
80 mg capsules x 2;
 125 mg capsule x 1

3 days

Fanapt (U.S. only)8
 
(iloperidone)

Titration pack:
1 mg tablets x 2;
2 mg tablets x 2;
4 mg tablets x 2;
 6 mg tablets x 2

 

4 days

Fetzima9
 
(levomilnacipran)

Titration pack (U.S. only):
20 mg capsules x 2;
 40 mg capsules x 40

42 days

Gralise (U.S. only)11
 
(gabapentin)

Starter pack:
300 mg tablets x 9;
 600 mg tablets x 69

 

 

30 days

Humira22
 
(adalimumab)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(All are only available in the U.S.)
Starter package for Crohn’s disease, ulcerative colitis, or hidradenitis suppurativa:
 
40 mg/0.8 mL pen x 6

Starter package for Crohn’s disease, ulcerative colitis, or hidradenitis suppurativa:
 
80 mg/0.8 mL pen x 3

Starter package for psoriasis, uveitis, or adolescent hidradenitis suppurativa:
 
40 mg/0.8 mL pen x 4

Starter package for psoriasis, uveitis, or adolescent hidradenitis suppurativa:
 
80 mg/0.8 mL pen x 1;
 40 mg/0.4 mL pen x 2

Starter package for pediatric Crohn’s disease:
 
40 mg/0.8 mL prefilled syringe x 6

Starter package for pediatric Crohn’s disease:
 
80 mg/0.8 mL prefilled syringe x 3

Starter package for pediatric Crohn’s disease:
 
40 mg/0.8 mL prefilled syringe x 3

Starter package for pediatric Crohn’s disease:
 
80 mg/0.8 mL prefilled syringe x 1;
 40 mg/0.4 mL prefilled syringe x1

Varies, depending on patient condition and dose.

Ingrezza (U.S. only)27
 
(valbenazine)

Initiation pack:
40 mg capsules x 7;
 80 mg capsules x 21

 

28 days

Lamictal12,29
 
(lamotrigine)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(All are only available in the U.S.)

Starter kit for patients taking valproate (blue kit):
 25 mg tablets x 35

 Lamictal ODT titration kit for patients taking valproate (blue ODT kit):
25 mg ODT x 21;
 50 mg ODT x 7

 Lamictal XR titration kit for patients taking valproate (blue XR kit):
25 mg Lamictal XR tablets x 21;
50 mg Lamictal XR tablets x7

 Starter kit for patients taking carbamazepine, phenytoin, phenobarbital, or primidone and NOT valproate (green kit):
25 mg tablets x 84;             
 100 mg tablets x 14

 Lamictal ODT titration kit for patients taking carbamazepine, phenytoin, phenobarbital, or primidone and NOT valproate (green ODT kit):
50 mg ODT x 42;
 100 mg ODT x 14

 Lamictal XR titration kit for patients taking carbamazepine, phenytoin, phenobarbital, or primidone and NOT valproate (green XR kit):
50 mg Lamictal XR tablets x 14;
100 mg Lamictal XR tablets x 14;
200 mg Lamictal XR tablets x 7

 Starter kit for patients NOT taking carbamazepine, phenytoin, phenobarbital, primidone, or valproate (orange kit):
25 mg tablets x 42;             
 100 mg tablets x 7

 Lamictal ODT titration kit for patients NOT taking carbamazepine, phenytoin, phenobarbital, primidone, or valproate (orange ODT kit):
25 mg ODT x 14;
50 mg ODT x 14;
 100 mg ODT x 7

 Lamictal XR titration kit for patients NOT taking carbamazepine, phenytoin, phenobarbital, primidone, or valproate (orange XR kit):
25 mg Lamictal XR tablets x 14;
50 mg Lamictal XR tablets x 14;
100 mg Lamictal XR tablets x 7

 

35 days

Medrol25
 
(methylprednisolone)

DOSEPAK (U.S. only):
 4 mg tablets x 21

6 days

Namenda (U.S. only)13
 
(memantine)

Titration pack:
5 mg tablets x 28;
 10 mg tablets x 21

 

28 days

Namenda XR (U.S. only)14
 
(memantine extended-release)

Titration pack:
7 mg capsules x 7;
14 mg capsules x 7;
21 mg capsules x 7;
 28 mg capsules x 7

28 days

Otezla15,16
 
(apremilast)

Two-week starter pack:
10 mg tablets x 4;
20 mg tablets x 4;
30 mg tablets x 5;
 Plus an additional 30 mg tablets x 14

 28-day starter pack (U.S. only):
10 mg tablets x 4;
20 mg tablets x 4;
30 mg tablets x 5;
 Plus an additional 30 mg tablets x 42

14 days (two-week pack)

 

 

 

 

 

28 days (28-day pack)

Rebif17
 
(interferon beta-1a)

(All available in U.S. only)
Titration pack:
8.8 mcg prefilled syringe x 6;
 22 mcg prefilled syringe x 6

 Rebidose titration pack:
8.8 mcg autoinjector x 6;             
 22 mcg autoinjectors x 6

 

 

28 days

Savella (U.S. only)18
 
(milnacipran)

Titration pack:
12.5 mg tablets x 5;
25 mg tablets x 8;
 50 mg tablets x 42

 

28 days

Tecfidera10
 
(dimethyl fumarate)

Starter pack (U.S. only):
 
120 mg capsules x 14;
 240 mg capsules x 46

  

30 days

Uptravi26
 
(selexipag)

Titration pack (U.S. only):
200 mcg tablets x 140;
 800 mcg tablets x 60

 

Varies, depending on tolerance of med and maintenance dose. 

Viibryd19
 
(vilazodone)

Starter kits:
(U.S. only)
10 mg tablets x 7;
20 mg tablets x 7;
40 mg tablets x 16
or
10 mg tablets x 7;
 20 mg tablets x 23

 

 

30 days

Xarelto21
 
(rivaroxaban)

Starter pack for treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) (U.S. only):
15 mg tablets x 42;
 20 mg tablets x 9

 

30 days

Zithromax23,24
(azithromycin)

Z-PAK:
250 mg tablets x 6

 TRI-PAK (U.S. only):
 500 mg tablets x 3

 

Z-PAK:  5 days

TRI-PAK:  3 days

  

Project Leader in preparation of this clinical resource (351213):  Stacy A. Hester, R.Ph., BCPS, Associate Editor

 

References

  1. Institute for Safe Medication Practices.   Community/Ambulatory Care.  ISMP Medication Safety Alert! August 2019.
  2. Product information for Adlyxin.  Sanofi-Aventis.  Bridgewater, NJ  08807.   January 2019.
  3. Product information for Cimzia.  UCB.   Smyrna, GA 30080.  September 2019.
  4. Product information for Avelox ABC Pack.  Schering-Plough.  Kenilworth, NJ  07033.   November 2011.
  5. Product information for Chantix.  Pfizer.   New York, NY  10017.  February 2019.
  6. Product monograph for Champix.  Pfizer Canada.  Kirkland, QC   H9J 2M5.  January 2019.  
  7. Product information for Eliquis.  Bristol-Myers Squibb.  Princeton, NJ   08543.  June 2019.
  8. Product information for Fanapt.  Vanda.   Washington, DC  20037.  January 2016.
  9. Product information for Fetzima.  Allergan.   Madison, NJ  07940.  October 2019.
  10. Product information for Tecfidera.  Biogen.   Cambridge, MA  02142.  July 2019.
  11. Product information for Gralise.  Depomed.   Newark, CA  94560.  October 2019.
  12. Product information for Lamictal.  GlaxoSmithKline.  Research Triangle Park, NC  27709.   September 2019.
  13. Product information for Namenda.  Allergan.   Madison, NJ  07940.  November 2018.
  14. Product information for Namenda XR.  Allergan.   Irvine, CA  92612.  October 2016.
  15. Product information for Otezla.  Celgene.   Summit, NJ  07901.  July 2019.
  16. Product monograph for Otezla.  Celgene.   Mississauga ON  L5N 7Y2.  November 2017.
  17. Product information for Rebif.  EMD Serono.   Rockland, MA  02370.  July 2019.
  18. Product information for Savella.  Allergan.   Irvine, CA  92612.  December 2017.
  19. Product information for Viibryd.  Allergan.   Madison, NJ  07940.  May 2018.
  20. Product monograph for Alunbrig.  Takeda Canada.  Oakville, ON L6H 0J8.  July 2018.
  21. Product information for Xarelto.  Janssen.   Titusville, NJ  08560.  October 2019.
  22. Product information for Humira.  Abbvie.   North Chicago, IL  60064.  January 2019.
  23. Product information for Zithromax.  Pfizer.   New York, NY 10017.  May 2019.
  24. Product monograph for Zithromax.  Pfizer Canada.  Kirkland, QC   H9J 2M5.  September 2018.
  25. Product information for Medrol.  Pharmacia & Upjohn.  New York, NY   10017.  September 2019.
  26. Product information for Uptravi.  Actelion.   South San Francisco, CA   94080.  September 2019.
  27. Product information for Ingrezza.  Neurocrine Biosciences.  San Diego, CA   92130.  July 2019.
  28. Product information for Alunbrig.  Takeda.   Cambridge, MA  02139.  December 2018.
  29. Product information for Lamictal XR.  GlaxoSmithKline.  Research Triangle Park, NC  27709.   September 2019.
  30. Product information for Emend.  Merck.   Whitehouse Station, NJ   08889.  September 2019.
  31. Product monograph for Emend.  Merck Canada.   Kirkland, QC  H9H 4M7.  January 2014.

  Cite this document as follows:  Clinical Resource, Dispensing Dose Packs.  Pharmacist’s Letter/Prescriber’s Letter.  December 2019.

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