TINDAL
Clinical safety rating: caution
Comprehensive clinical and safety monograph for TINDAL (TINDAL).
TINDAL (trimethoprim) inhibits bacterial dihydrofolate reductase (DHFR), preventing the reduction of dihydrofolate to tetrahydrofolate, thereby inhibiting bacterial DNA synthesis.
| Metabolism | Hepatic metabolism via cytochrome P450 enzymes (primarily CYP3A4) and other pathways. |
| Excretion | Primarily renal excretion of unchanged drug (70-80%) and hepatic metabolism (20-30%). |
| Half-life | Terminal elimination half-life is approximately 12-15 hours in adults with normal renal function; prolonged in renal impairment. |
| Protein binding | Approximately 85-90% bound to serum albumin. |
| Volume of Distribution | Apparent volume of distribution is 0.6-0.8 L/kg, indicating distribution into total body water. |
| Bioavailability | Oral bioavailability is 60-70% due to first-pass metabolism. |
| Onset of Action | Oral: 1-2 hours; Intravenous: 15-30 minutes. |
| Duration of Action | Duration is 6-8 hours for oral dosing; clinical effect correlates with serum levels above minimum inhibitory concentration. |
TINDAL (ticarcillin disodium + clavulanate potassium) 3.1 g (ticarcillin 3 g + clavulanic acid 0.1 g) IV every 4-6 hours. Maximum dose: 18 g ticarcillin/0.6 g clavulanic acid per day.
| Dosage form | TABLET |
| Renal impairment | CrCl > 60 mL/min: 3.1 g q4-6h. CrCl 30-60 mL/min: 2 g q4h. CrCl 10-30 mL/min: 2 g q8h. CrCl < 10 mL/min: 2 g q12h. Hemodialysis: 2 g q12h with additional 2 g after dialysis. |
| Liver impairment | No dosage adjustment required for hepatic impairment. Clavulanic acid is hepatically metabolized, but no specific Child-Pugh adjustments are established. Monitor transaminases. |
| Pediatric use | Children ≥ 3 months: 200 mg ticarcillin/kg/day (based on ticarcillin component) divided q4-6h IV. For moderate to severe infections: 300 mg/kg/day divided q4h. Maximum dose: 18 g ticarcillin/day. For neonates (≤ 7 days): 150 mg/kg/day divided q12h. For neonates (8-28 days): 225 mg/kg/day divided q8h. |
| Geriatric use | Elderly patients often have reduced renal function; adjust dose based on creatinine clearance. Start at lower end of dosing range due to increased risk of bleeding and electrolyte disturbances. Monitor renal function, coagulation parameters, and electrolytes regularly. |
| 1st trimester | Consult provider |
| 2nd trimester | Consult provider |
| 3rd trimester | Consult provider |
Clinical note
Comprehensive clinical and safety monograph for TINDAL (TINDAL).
| Breastfeeding | Indapamide is excreted in human milk in small amounts. The M/P ratio is unknown. Due to potential for adverse effects in the nursing infant, including electrolyte imbalance and hypovolemia, caution is advised. It is generally recommended to avoid breastfeeding while taking indapamide or to use an alternative agent with a better-established safety profile. |
| Teratogenic Risk | TINDAL (indapamide) is not generally recommended during pregnancy, especially in the first trimester. Animal studies have shown no teratogenic effects, but there are no adequate human studies. Due to the potential for decreased placental perfusion and fetal abnormalities associated with thiazide-like diuretics, use during pregnancy, particularly the second and third trimesters, may cause fetal or neonatal jaundice, thrombocytopenia, and electrolyte disturbances. Risk cannot be excluded. |
■ FDA Black Box Warning
No FDA black box warning.
| Serious Effects |
["Hypersensitivity to trimethoprim or any component of the formulation","Megaloblastic anemia due to folate deficiency","Severe renal impairment (CrCl <15 mL/min) unless dialysis is available","Concurrent use with methotrexate (increased risk of methotrexate toxicity)"]
| Precautions | ["Monitor renal function; dose adjustment required in renal impairment (CrCl <30 mL/min)","Risk of hyperkalemia, especially in patients with renal impairment or on potassium-sparing diuretics","Hematologic toxicity (megaloblastic anemia) with prolonged use; monitor CBC in patients at risk of folate deficiency","Photosensitivity; avoid excessive sunlight or UV exposure"] |
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| Fetal Monitoring | Maternal monitoring includes blood pressure, serum electrolytes (especially potassium and sodium), renal function, and uric acid levels. Fetal monitoring may include ultrasound assessment of growth and amniotic fluid volume due to potential for reduced placental perfusion. Neonatal monitoring for hypoglycemia, electrolyte disturbances, and jaundice is recommended if used near term. |
| Fertility Effects | No specific data on fertility effects in humans. In animal studies, no adverse effects on fertility were observed. However, as an antihypertensive, indapamide may be used in conditions that themselves can affect fertility; no direct effect on reproductive organs or spermatogenesis has been reported. |