Nystatin: Nursing Drug Guide, Swish-and-Hold Technique & NCLEX Review
Healthcare medication guide: the highest-stakes nursing failures with nystatin are swallowing oral suspension immediately (instead of swishing and retaining contact time), using the wrong formulation or route (topical cream or powder for oral thrush), and missing hypersensitivity when oral irritation, rash, or bronchospasm develops. Verify product, dose, and technique before every administration.
Nystatin oral suspension treats oral cavity candidiasis only when the drug contacts mucosa long enough to work—labeling requires retaining the preparation in the mouth as long as possible before swallowing. Swallowing immediately, giving the wrong product (topical cream, powder, or vaginal preparation for oral thrush), or using nystatin for systemic mycoses (not absorbed from the GI tract) are common nursing-adjacent failures. Topical nystatin is not for oral, systemic, intravaginal, or ophthalmic use. Discontinue and escalate if hypersensitivity, bronchospasm, facial swelling, or severe rash occurs. Continue therapy at least 48 hours after perioral symptoms resolve and cultures clear.
📋 Contents
⚡ Quick facts
*Formulation-specific — verify product label before administration.
💡 Key takeaway
Oral nystatin only works when it contacts oral mucosa: swish, split the dose between both sides of the mouth, and retain as long as possible before swallowing—then avoid feeding infants for 5–10 minutes. Confirm you have the correct formulation (oral suspension for thrush, not topical cream or powder). Hold and escalate if hypersensitivity, bronchospasm, or worsening irritation appears.
Most common brand names
Nystatin is available as generic and brand-name products in several formulations—oral suspension, topical cream, ointment, and powder. Formulations are not interchangeable: oral suspension treats candidiasis in the oral cavity; topical products treat cutaneous or mucocutaneous candidiasis and must not be used orally, intravaginally, or in the eye per labeling.
Common brand names include Mycostatin, Nilstat, Bio-Statin, and Nystex (oral and topical lines vary by manufacturer). When thrush persists or the patient cannot retain oral suspension, prescribers may switch to another antifungal such as clotrimazole troches or fluconazole per order—verify the new product’s route and technique before administration.
Why we give it — Indications
Nystatin treats Candida infections on the body surface or in the mouth. Nurses most often give oral suspension for oral thrush (oral candidiasis)—common in infants, older adults, and patients with type 2 diabetes, inhaled corticosteroid use, antibiotic therapy, or HIV/AIDS and other immunocompromising conditions. Topical nystatin treats cutaneous or mucocutaneous candidiasis such as intertrigo, diaper dermatitis, and some skin-fold infections; it is not indicated for systemic, oral, intravaginal, or ophthalmic use—vaginal yeast infection requires a product labeled for that route.
| Use | Detail |
|---|---|
| Oral candidiasis (thrush) | Oral suspension is indicated for candidiasis in the oral cavity. Therapy depends on contact time with oral mucosa—not simply swallowing the dose. |
| Cutaneous / mucocutaneous candidiasis | Topical cream, ointment, or powder is indicated for infections caused by Candida albicans and other susceptible Candida species on intact or affected skin. |
| Moist lesions | Labeling notes that very moist lesions may be best treated with topical dusting powder rather than cream alone. |
| Not indicated — systemic mycoses | Oral nystatin is not for systemic fungal disease; GI absorption is insignificant and most drug passes unchanged in stool. |
| Not indicated — topical wrong routes | Topical nystatin is not for systemic, oral, intravaginal, or ophthalmic use. Do not apply topical cream to nail fungus or deep nail infections unless the prescriber specifies an appropriate topical product and realistic expectations—onychomycosis often needs different therapy. |
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How it works
Nystatin is a polyene antifungal antibiotic obtained from Streptomyces noursei. It binds to sterols in the cell membrane of susceptible yeasts and yeast-like fungi (including Candida albicans), altering membrane permeability and causing leakage of intracellular components. It is fungistatic and fungicidal in vitro; C. albicans generally does not develop resistance on repeated exposure. Nystatin has no appreciable activity against bacteria, protozoa, or viruses.
Because oral nystatin is poorly absorbed from the GI tract, its antifungal effect in thrush depends on prolonged contact with infected mucosa—the nursing “swish-and-hold” technique is not optional. Topical products act locally on the skin or mucocutaneous surface and are not absorbed from intact skin or mucous membrane per labeling.
Dosing overview
Always verify the prescriber order against current prescribing information, patient age, and the specific formulation dispensed (oral suspension concentration is 100,000 units/mL—shake well before measuring). Renal or hepatic dose adjustment is not specified in the reviewed DailyMed labeling for oral suspension or topical cream.
Oral suspension dosing (100,000 units/mL — Taro labeling)
| Population | Dose | Frequency | Administration notes |
|---|---|---|---|
| Infants and young children | 2 mL (200,000 units) | Four times daily | Use dropper; place one-half of dose on each side of mouth; avoid feeding for 5–10 minutes after dose |
| Premature / low birth weight infants | 1 mL (100,000 units) | Four times daily | Supported by limited clinical studies per labeling |
| Children and adults | 4–6 mL (400,000–600,000 units) | Four times daily | Place one-half of dose on each side of mouth; retain in mouth as long as possible before swallowing |
| All oral patients | Continue therapy | At least 48 hours after | Perioral symptoms have disappeared and cultures demonstrate eradication of Candida albicans |
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Topical cream dosing (100,000 units/g)
| Population | Application | Frequency | Notes |
|---|---|---|---|
| Adults and pediatric patients (neonates and older) | Apply liberally to affected areas | Twice daily (or as indicated) | Continue until healing is complete; not for oral, systemic, intravaginal, or ophthalmic use |
| Very moist lesions | Topical dusting powder | Per prescriber | Labeling recommends powder for very moist lesions; verify product type on MAR |
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Missed dose: Not specified in the reviewed prescribing information. Do not double doses; contact pharmacy or prescriber for guidance on the next scheduled dose.
Onset, peak, duration, and half-life
| Parameter | Value | Nursing relevance |
|---|---|---|
| Oral GI absorption | Insignificant; most drug passed unchanged in stool | Antifungal effect in thrush requires mucosal contact—swallowing quickly without swishing defeats therapy |
| Topical absorption | Not absorbed from intact skin or mucous membrane | Local application only; wrong route (oral ingestion of cream) does not treat thrush and may cause GI upset or sensitization |
| Systemic levels (oral) | Generally negligible; occasional plasma levels in renal insufficiency | Oral nystatin is not systemic therapy—do not expect treatment of invasive or disseminated candidiasis |
| Onset / duration | Not quantified in labeling | Clinical improvement of oral or skin lesions expected over days; continue ≥48 h after symptoms resolve and cultures negative (oral) |
| Half-life / peak | Not specified in reviewed labeling | QID oral scheduling supports sustained mucosal contact rather than systemic trough/peak monitoring |
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Before you give it — Safety check
Pretreatment checks
- Confirm the ordered formulation matches the indication: oral suspension for oral candidiasis; topical product for cutaneous infection—read the label and compare to the MAR during medication reconciliation
- Review allergy history to nystatin and excipients (parabens, sucrose, alcohol in oral suspension); prior antifungal hypersensitivity
- For oral doses: verify calibrated dropper or dosing device, shake suspension well, and plan uninterrupted mouth-contact time (hold feeds in infants 5–10 minutes after dose)
- For topical doses: confirm affected area is appropriate for topical antifungal; ensure product is not intended for eyes, mouth, or vagina unless specifically labeled
Contraindications
- Hypersensitivity to nystatin or any component of the specific formulation
- Oral suspension: not for treatment of systemic mycoses
- Topical cream/powder: not for systemic, oral, intravaginal, or ophthalmic use per labeling
Important interactions
| Drug / factor | Effect | Nursing action |
|---|---|---|
| Drug–drug interactions | Not specified in the reviewed DailyMed prescribing information for oral suspension or topical cream | Still screen the MAR for overlapping antifungals and duplicate therapy; clarify with pharmacy if two candidiasis treatments are ordered |
| Renal / hepatic impairment | Dose adjustment not specified in reviewed labeling; occasional plasma nystatin with oral therapy in renal insufficiency | Monitor for unexpected systemic symptoms; escalate per prescriber if oral therapy continues in significant renal impairment |
| Wrong formulation / route | Topical product ingested or oral suspension applied to skin—therapy failure and irritation risk | Hold, verify product with pharmacy, re-educate patient/caregiver on correct technique before resuming |
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Administration
Oral suspension: Shake well before each use. Measure with the calibrated dropper supplied or pharmacy-provided oral syringe. For infants and young children, place one-half of each dose on each side of the mouth using the dropper; avoid feeding for 5–10 minutes afterward so the drug contacts mucosa. For children and adults, swish and retain the suspension in the mouth as long as possible before swallowing—splitting the dose between both sides improves coverage of cheeks, tongue, and palate.
Topical cream: Apply a liberal layer to clean, affected skin twice daily (or as ordered) until healing is complete. Wash hands before and after application unless treating hand involvement. Do not cover with occlusive dressings unless ordered. Do not apply to eyes, inside the mouth, or vagina.
- Follow the five rights during every medication administration pass—wrong product (cream vs suspension) is a common nystatin error
- Document technique teaching for swish-and-hold and infant “no feeding” window on the MAR
- Store oral suspension at controlled room temperature; protect from freezing per labeling
- After topical application, observe for local burning, itching, or worsening erythema at the next assessment
The most common nursing-related treatment failure is giving oral nystatin like a routine oral liquid—measuring correctly but allowing immediate swallowing, bottle feeding, or pacifier use before mucosal contact. In infants, skipping the 5–10 minute feeding hold has the same effect. Thrush may persist despite “perfect” QID scheduling until technique is corrected.
Expected therapeutic response
- Reduction of white plaques, erythema, and discomfort in oral candidiasis; improved feeding or swallowing comfort in infants when thrush was causing irritability
- Healing of cutaneous candidiasis lesions with decreased erythema, maceration, and satellite papules on topical therapy
- Resolution of perioral symptoms followed by negative fungal cultures when cultures are obtained—oral labeling requires continuing therapy ≥48 hours after symptoms disappear and cultures show eradication
- Absence of new fever or spreading erythema suggesting secondary bacterial infection or treatment failure—escalate if lesions worsen despite correct technique
Red flags — Stop and act
Hypersensitivity and serious skin reactions are uncommon but reported. Hold nystatin and escalate immediately if systemic allergy or severe mucocutaneous reaction develops—especially after a formulation or route mix-up.
- Anaphylaxis cues: bronchospasm, facial swelling, urticaria, hypotension, or difficulty breathing after oral or topical nystatin
- Serious mucocutaneous reactions: widespread rash, blistering, or mucosal sloughing—Stevens-Johnson syndrome reported very rarely per oral labeling
- Local allergic rash, oral irritation, or sensitization that worsens with each dose—labeling directs discontinuation if sensitization or irritation occurs
- Accidental ingestion of large topical quantity or persistent GI toxicity after oral overdose—see overdose section
- Thrush or skin infection worsening after 3–5 days of correct technique—may need culture, alternate antifungal, or evaluation for non-Candida cause
Adverse effects
| Adverse effect | Frequency / context | Nursing response |
|---|---|---|
| Nausea, vomiting, GI upset | Reported with oral therapy; overdose >5 million units daily caused nausea and GI upset per labeling | Supportive care; verify dose and technique; hold and notify prescriber if severe or persistent |
| Diarrhea | Reported including one case of bloody diarrhea in oral labeling | Hold nystatin, assess hydration, notify prescriber; rule out other causes |
| Oral irritation / sensitization | Reported with prolonged oral therapy | Discontinue per labeling; differentiate from untreated thrush plaques |
| Topical: burning, itching, eczema, pain on application | Frequency <0.1% in topical cream trials | Stop application; notify prescriber for alternate antifungal |
| Rash / urticaria | Rare (dermatologic labeling) | Hold drug; monitor for progression to serious skin reaction |
| Bronchospasm, facial swelling, tachycardia, myalgia | Very rarely reported (oral labeling) | Stop nystatin; emergency escalation for airway or anaphylaxis protocol per facility policy |
| Stevens-Johnson syndrome | Very rarely reported (oral labeling) | Stop drug immediately; urgent prescriber and dermatology/emergency pathway |
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Overdose, toxicity, and antidote
Oral nystatin overdoses are uncommon because systemic absorption is minimal, but excessive oral dosing has been reported.
Reported overdose effects
- Oral doses in excess of five million units daily have caused nausea and gastrointestinal upset per Taro oral suspension labeling
- No reports of serious toxic effects or superinfections linked to oral overdose in the reviewed labeling
Management
Supportive care per clinical status—monitor for persistent nausea, vomiting, or diarrhea. No specific antidote is listed in the reviewed prescribing information. Contact local poison control or toxicology services per facility protocol if large ingestion is suspected.
Look-alike / sound-alike and error prevention
- Nystatin oral suspension vs nystatin topical cream/ointment/powder—identical generic name, different routes; store separately and read label before every dose
- Nystatin vs nystatin/triamcinolone combination products—steroid-containing combo treats inflammation but adds corticosteroid risks; verify exact product on MAR
- Units vs milliliters—oral suspension is 100,000 units/mL; 4 mL = 400,000 units; do not confuse with mg dosing
- Oral suspension vs “swallow and chase” liquids—technique errors mimic wrong-drug errors because the patient receives the right drug incorrectly
- Topical nystatin vs intravaginal antifungal—topical nystatin is not for intravaginal use; vaginal yeast orders need a labeled vaginal product
Practical bedside notes
| Topic | Bedside guidance |
|---|---|
| Shake well | Oral suspension requires shaking before each measurement—unshaken bottles deliver inconsistent unit doses |
| Infant technique | Split dose cheek-to-cheek with dropper; delay feeds 5–10 minutes; document caregiver teach-back in NICU/peds |
| Adult / child oral technique | Swish, gargle if able, and hold—minimum several minutes; avoid eating/drinking immediately after when possible |
| Topical application | Apply liberally BID to affected area until healed; use powder for very moist intertriginous sites when ordered |
| Commonly missed | Stopping when plaques look better (before 48 h post-symptom resolution and negative culture); applying topical cream inside the mouth; pacifier/bottle right after infant dose |
| Ask pharmacy when | Formulation substitution, sucrose content concerns in diabetes, or need for alternate antifungal if nystatin not tolerated |
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High-risk populations
| Population | Considerations |
|---|---|
| Premature / low birth weight infants | 1 mL QID supported by limited studies; meticulous swish-and-hold and feeding hold essential in NICU |
| Immunocompromised patients | Oral thrush may recur or need systemic therapy if extensive—nystatin treats local oral disease only; monitor for treatment failure |
| Diabetes mellitus | Hyperglycemia predisposes to oral and cutaneous candidiasis; coordinate thrush treatment with blood glucose monitoring and glycemic management per care plan |
| Older adults | Denture-related candidiasis may need device cleaning and prolonged contact time; greater sensitivity to irritation cannot be ruled out |
| Pregnancy | Pregnancy category C—animal reproduction studies not conducted; use only if clearly needed per oral/topical labeling |
| Lactation | Not known whether nystatin is excreted in human milk; caution when administered to nursing women per labeling |
| Sucrose-containing oral suspension | Oral suspension contains sucrose (49.8% w/v per Taro labeling)—consider glycemic and dental implications in high-risk patients |
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Monitoring and documentation
Monitor
- Oral mucosa or skin lesion appearance at each shift—plaque resolution, erythema, fissures, satellite lesions
- Signs of hypersensitivity: new rash, urticaria, facial swelling, wheeze, or oral irritation after doses
- GI tolerance with oral therapy—nausea, vomiting, diarrhea, especially if doses exceed labeling ranges
- Culture results when ordered—continue oral therapy ≥48 h after symptoms gone and cultures negative
- Technique adherence: caregiver demonstration of swish-and-hold and infant feeding hold
Document
- Formulation, dose in mL, units, route, time, and patient tolerance on the MAR
- Swish-and-hold and infant “no feeding for 5–10 minutes” teaching provided per documentation standards
- Any hold events, hypersensitivity symptoms, and prescriber/pharmacy notification
- Topical site assessed before and after application when institutional policy requires
Patient teaching
- Shake oral suspension well; measure with supplied dropper or syringe—do not use household spoons
- Swish and hold in the mouth as long as possible before swallowing; split dose between both sides of the mouth
- For infants: place half the dose on each cheek and wait 5–10 minutes before feeding
- Complete the full course even if white patches disappear—labeling requires ≥48 hours after symptoms resolve and negative cultures
- Topical cream is for skin only—not for mouth, eyes, or vagina; wash hands after application
- Report trouble breathing, facial swelling, severe rash, worsening mouth pain, or bloody diarrhea immediately
The Hold Rule
Do not give and contact the prescriber/pharmacist when:
- Known hypersensitivity to nystatin or formulation excipients
- Wrong product dispensed or ordered (e.g., topical cream for oral thrush, oral suspension for cutaneous site only)
- New bronchospasm, facial swelling, widespread rash, or other anaphylaxis cues after a dose
- Oral irritation or topical sensitization worsening with continued use—labeling directs discontinuation
- Order exceeds safe oral volume/units without prescriber clarification (overdose threshold >5 million units daily in labeling)
- Patient cannot perform or tolerate required swish-and-hold or infant feeding hold—needs alternate formulation or antifungal plan
Hold parameters may vary by institutional protocol. Follow prescriber orders, pharmacy guidance, and facility policy.
Clinical practice integration and workflow
Oral nystatin is deceptively simple on the MAR—QID liquid—yet treatment fails when nurses or parents administer it like a quick oral medication. Build swish-and-hold technique and formulation verification into every pass, especially on pediatrics, oncology, and med-surg units where thrush overlaps with antibiotics and steroids.
1. Check-before-you-give protocol
- Right patient, dose, route, time—and right formulation (suspension vs cream vs powder)
- Oral: shake, measure mL, plan cheek-to-cheek or swish time before swallowing
- Infants: confirm feeding hold window and dropper technique with bedside caregiver
- Compare dispensed product to MAR during admission and after pharmacy substitution
2. High-alert and safety badge
Formulation and technique critical — wrong route or swallow-only dosing causes failureNystatin is not an ISMP high-alert medication, but oral/topical mix-ups and swish-and-hold omissions produce the same outcome as a wrong-drug error: persistent candidiasis and delayed escalation to systemic antifungals.
3. Clinical workflow: hold and question rules
- If plaques persist after 5–7 days of documented correct QID technique, notify prescriber—may need culture or alternate agent
- If topical cream is on the MAR for “thrush,” hold and clarify—oral suspension is the labeled oral product
- Any facial swelling, wheeze, or urticaria after dose triggers hold and allergy pathway before the next scheduled dose
4. Critical teach-back questions
- “Show me how you will give this dose in the mouth before swallowing.” (Caregiver should demonstrate cheek placement or swish-and-hold—not immediate swallow.)
- “How long should you wait to feed the baby after the dose?” (Caregiver should state 5–10 minutes for infants per labeling.)
5. Care coordination
Pharmacist: Formulation verification, sucrose content concerns, alternate antifungal if nystatin not tolerated, culture-guided therapy
Prescriber: Persistent thrush despite correct technique, recurrent candidiasis in immunocompromised or diabetic patients, hypersensitivity, need for systemic therapy
🧠 Quick mental checklist
- Is this the oral suspension for thrush—or a topical product that must not be swallowed?
- Did I shake the bottle and measure the correct mL (100,000 units/mL)?
- Will the dose stay in the mouth long enough—cheek-to-cheek in infants with a 5–10 minute feeding hold?
- Any new rash, facial swelling, wheeze, or oral burning since the last dose?
- Have symptoms resolved and cultures turned negative before stopping—continuing ≥48 h after per labeling?
Nystatin NCLEX practice questions
Practice NCLEX-style clinical judgment practice for nystatin swish-and-hold technique and formulation safety using a tabbed inpatient case (MAR, labs, history, nursing notes), then priority action, cue recognition (SATA), symptom trend interpretation, documentation cloze, clinical judgment MCQ, and matrix urgency sorting—recognise cues → analyse → prioritise → act → evaluate outcomes.
Select a tab to view MAR, labs, history, and nursing note details for this case.
- Nystatin oral suspension 5 mL (500,000 units) QID — 0800, 1200, 1600 given; next due 2000
- Pharmacy label: Nystatin Oral Suspension USP 100,000 units/mL — shake well
- Metformin 500 mg BID with meals; inhaled budesonide/formoterol BID
- 0400 MAR note: night nurse documented patient “swallowed dose quickly after receiving cup”
- Fasting glucose today: 218 mg/dL (prior 192 mg/dL)
- HbA1c (admission): 8.9%
- Oral fungal culture (day 1): Candida albicans — repeat culture pending day 5
- CBC, BMP otherwise within baseline; no routine nystatin level monitoring per labeling
- 68-year-old with type 2 diabetes; admitted for cellulitis treated with IV antibiotics (now completed)
- Reports dry mouth, white patches on buccal mucosa and tongue for 5 days
- Uses dentures; removed at bedtime; poor denture hygiene acknowledged
- No known drug allergies documented; no prior nystatin exposure
- Day 3 oral exam: white plaques remain on tongue and buccal mucae despite 3 days of therapy
- Patient states he “just drinks it down” because the suspension tastes unpleasant
- 1600 dose: nurse observed patient rinse once and swallow within 10 seconds
- Teaching sheet on swish-and-hold in chart; patient unable to demonstrate correct technique on teach-back
Answer key & rationale
Frequently asked questions
How long should nystatin oral suspension stay in the mouth?
Labeling states the preparation should be retained in the mouth as long as possible before swallowing. For infants and young children, place half the dose on each side of the mouth and avoid feeding for 5 to 10 minutes after the dose.
Can nystatin cream or powder treat oral thrush?
No. Topical nystatin cream and powder are indicated for cutaneous or mucocutaneous fungal infections and are not for oral, systemic, intravaginal, or ophthalmic use. Oral candidiasis requires nystatin oral suspension or another oral antifungal per prescriber order.
When should a nurse hold nystatin?
Hold for documented hypersensitivity to nystatin or any component, wrong formulation or route for the indication, new rash with bronchospasm or facial swelling, oral irritation suggesting sensitization, or when the patient cannot safely follow swish-and-hold technique without an alternative plan from the prescriber or pharmacist.
Is nystatin absorbed and useful for systemic fungal infection?
No. Gastrointestinal absorption of nystatin is insignificant; most orally administered drug passes unchanged in stool. Oral suspension treats candidiasis in the oral cavity only—not systemic mycoses.
What are signs of nystatin overdose or toxicity?
Oral doses in excess of five million units daily have caused nausea and gastrointestinal upset per labeling. No specific antidote is listed; management is supportive. Contact poison control or medical toxicology services per facility protocol and local emergency guidance for significant ingestion concerns.
How long should nystatin continue after thrush looks better?
Continue for at least 48 hours after perioral symptoms have disappeared and cultures demonstrate eradication of Candida albicans per oral suspension labeling—stopping when plaques merely look improved can allow relapse.
References
- U.S. National Library of Medicine. Nystatin Oral Suspension, USP — Full prescribing information. DailyMed (Taro Pharmaceuticals U.S.A., Inc.).https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=01c469b3-ec10-452c-8c02-3e7d22e40297&type=display
- U.S. National Library of Medicine. Nystatin Cream USP — Full prescribing information. DailyMed (Padagis Israel Pharmaceuticals Ltd).https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=e630aa3d-11a6-4300-942a-cbdf2d016f77&type=display
- U.S. National Library of Medicine. Nystatin topical powder — Full prescribing information. DailyMed.https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=9e122c5f-65e4-4c92-aaa0-ae97dd725b1a&type=display
- Drugs and Lactation Database (LactMed). Nystatin. Bethesda (MD): National Institute of Child Health and Human Development.https://www.ncbi.nlm.nih.gov/books/NBK501922/
- MedlinePlus. Nystatin. U.S. National Library of Medicine.https://medlineplus.gov/druginfo/meds/a682758.html
Review and transparency
This medication guide is written and reviewed using NurseOnShift editorial and clinical review standards.
Educational use only. This content does not replace clinical judgment, prescriber orders, pharmacist guidance, product labeling, or institutional protocols.