Second-line agent

Generally, arblockers are considered as second-line agents to be added on to most other agents when hypertension is not adequately controlled. They may have a specific role in the antihypertensive regimen for elderly males with prostatism however, their use is often curtailed by complaints of syncope, dizziness, or palpitations following the first dose and orthostatic hypotension with chronic use. The roles of doxazosin, terazosin, and prazosin in the management of patients with hypertension are limited due to the paucity of outcome data and the absence of a unique role for special populations or compelling indications from JNC 7. 

Lanthanum Fosrenol 250, 500 — 750-1500 mg Second-line agent more expensive... 

Misra (2006)48 Seizure control Resp/cardiac events As second line agent,... 

Diphenhydramine 12.5-25 mg orally four times daily Second-line agent... 

Ondansetron (Zofran) 20 mg intravenously every 8 hours Second-line agent, may be preferred for hyperemesis... 

Bisacodyl (Dulcolax, 5-10 mg orally (tabs) or rectally Second-line agent after bulk laxatives... 

Ranitidine (Zantac) 150 mg orally twice daily Second-line agent after antacids... 

Ibuprofen (Advil, Motrin) 200-400 mg orally four times daily Second-line agent in first trimester only. Do not use in second or third trimester. 

Cetirizine (Zyrtec) 10 mg orally daily Second-line agent for allergic rhinitis during second and third trimesters only. 

Clindamycin (Cleocin) 300 mg orally twice daily for 7 days Oral administration is second-line agent in pregnancy ... 

Spectinomycin (Trobicin) Herpes Simplex Virus 2 g intramuscularly once Second-line agent in pregnancy for cephalosporin-allergic patients... 

Erythromycin (Ery-tab) Nipple Candidiasis 333 mg orally three times daily x 10-14 days Second-line agent in penicillin-allergic patients... 

Fluconazole (Diflucan) 100 mg orally daily Second-line agent when topical azoles fail... 

Although tetracycline, doxycycline, and minocycline are the most commonly prescribed oral antibiotics for acne, erythromycin and clindamycin are appropriate second-line agents for use when patients cannot tolerate or have developed resistance to tetracycline or its derivatives.3 See Table 62-3 for antibiotic dosing guidelines. 

The principal use of niacin is for mixed hyperlipidemia or as a second-line agent in combination therapy for hypercholesterolemia. It is a first-line agent or alternative for the treatment of hypertriglyceridemia and diabetic dyslipidemia. 

Gabapentin inhibits high-voltage activated Ca channels and elevates human brain GABA levels. It is a second-line agent for patients with partial seizures who have failed initial treatment. It may also have a role in patients with less severe seizure disorders, such as new-onset partial epilepsy, especially in elderly patients. 

It is a second-line agent for partial seizures that have failed initial treatment. 

Second-line agent for moderate-to-severe pain... 

It is considered a second-line agent for GAD because of inconsistent reports of efficacy, delayed onset of effect, and lack of efficacy for comorbid depressive and anxiety disorders (e.g., panic disorder or SAD). It is the agent of choice in patients who fail other anxiolytic therapies or in patients with a history of alcohol or substance abuse. It is not useful for situations requiring rapid antianxiety effects or as-needed therapy. 

BZs are second-line agents except when rapid response is essential. They should not be used as monotherapy in panic disorder patients with a history of depression or alcohol or drug abuse. BZs are often used concomitantly with antidepressants in the first weeks to offset the delay in onset of antipanic effects. 

Drugs of choice are isoniazid, rifampin, ethambutol, along with streptomycin and pyrazinamide. Less well tolerated, second-line agents include p-aminosal-icylic acid, cycloserine, viomycin, ka-namycin, amikacin, capreomycin, ethionamide. 

Unlabeled uses Bretylium is a second-line agent following lidocaine in the protocol for advanced cardiac life support during CPR. For resistant VF and VT (after lidocaine, defibrillation, and procainamide failures), give bretylium 5 to 10 mg/kg IV repeat as needed up to 30 mg/kg use a bolus every 15 to 30 minutes, infusion 1 to 2 mg/min. For life-threatening arrhythmia use an undiluted infusion of 1 g/250 mL. 

Pemetrexed is chemically similar to folic acid. It inhibits three enzymes used in purine and pyrimidine synthesis - thymidylate synthetase, dihydrofolate reductase, and glycinamide ribonucleotide formyl transferase. By inhibiting the formation of precursor purine and pyrimidine nucleotides, pemetrexed prevents the formation of DNA and RNA. In 2004 it was approved for treatment of malignant pleural mesothelioma and as a second-line agent for the treatment of non-small cell lung cancer. Adverse effects include gastrointestinal complaints, bone marrow suppression, alopecia, allergic and neurotoxic reactions. 

Geriatric Considerations-Summary Although tricyclic antidepressants are effective in the treatment of major depression in older adults, the side-effect profile and low toxic-to-therapeutic ratio relegate them to second-line agents (after serotonin reuptake inhibitors) for most older patients. These agents are effective in the treatment... 

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