Overnight Cross-Cover Quick Reference

Tiered medication tables for common overnight pages — first-line, second-line, and third-line options with contraindications.

General Principles

Always address the underlying cause before reflexively ordering medications — pain, urinary retention, constipation, missed home medications, and anxiety are common drivers of many overnight complaints.
Avoid PRN IV antihypertensives for asymptomatic elevated BP — per the ACC/AHA 2017 Hypertension Guideline, IV therapy is not recommended without acute end-organ damage.
Avoid sliding-scale-only insulin without basal insulin — the ADA strongly discourages this approach (ADA Standards of Care).
Avoid first-generation antihistamines (diphenhydramine) in elderly patients for any indication (insomnia, pruritus, nausea) due to anticholinergic burden, fall risk, and delirium risk per the AGS Beers Criteria.
Delirium management should prioritize nonpharmacologic interventions; antipsychotics have not been shown to reduce delirium duration or severity (NEJM MIND-USA Trial).
Never attribute chest pain to a benign cause without an ECG and troponin. See chest pain section below.

1. Headache / Pain (Mild-Moderate)

Tier	Medication	Contraindications / Cautions
First-Line	Acetaminophen 650 mg PO q4h or 1 g PO q6h (max 4 g/day; 2–3 g/day if elderly or liver disease)	Severe hepatic impairment, active liver disease, chronic alcohol use
Second-Line	Ibuprofen 400 mg PO q6h or ketorolac 15–30 mg IV q6h (max 5 days)	Renal insufficiency (CrCl <30), active GI bleeding, heart failure, anticoagulation, platelet dysfunction, third-trimester pregnancy
Third-Line	Metoclopramide 10 mg IV or prochlorperazine 10 mg IV (migraine-type)	Metoclopramide: Parkinson disease, seizure disorder, bowel obstruction, QTc prolongation. Prochlorperazine: Parkinson disease, Lewy body dementia, jaundice, QTc prolongation; obtain ECG before use

For comprehensive pain management including PCA, renal/hepatic dosing, and MME conversion see Pain Management.

2. Nausea / Vomiting

Tier	Medication	Contraindications / Cautions
First-Line	Ondansetron 4 mg IV/PO q6–8h	QTc prolongation (obtain ECG if concern); max 16 mg/day IV; constipation; reduce to ≤8 mg/day in hepatic impairment (Child-Pugh B/C)
Second-Line	Metoclopramide 10 mg IV/PO q6h	Parkinson disease, bowel obstruction, seizure disorder, pheochromocytoma; EPS risk (infuse over 15 min); 50% dose reduction in hepatic impairment; FDA black box for tardive dyskinesia with use >12 weeks
Third-Line	Prochlorperazine 5–10 mg IV/PO q6h or promethazine 12.5–25 mg IV/PO	Prochlorperazine: QTc prolongation, Parkinson disease, Lewy body dementia, jaundice. Promethazine: significant sedation, anticholinergic burden — avoid in elderly (Beers Criteria); tissue necrosis risk with IV extravasation (use large vein)

3. Insomnia

Tier	Medication	Contraindications / Cautions
First-Line	Melatonin 0.5–5 mg PO at bedtime (after nonpharmacologic measures: reduce noise, lights, cluster care)	Few contraindications; may interact with warfarin (monitor INR); limited evidence for inpatient efficacy
Second-Line	Trazodone 25–50 mg PO at bedtime	Orthostatic hypotension (fall risk), priapism (rare), QTc prolongation at higher doses, serotonin syndrome risk with SSRIs/SNRIs
Third-Line	Low-dose doxepin (3–6 mg) or ramelteon 8 mg PO	Doxepin: anticholinergic effects — avoid in urinary retention, narrow-angle glaucoma, dementia. Ramelteon: avoid with fluvoxamine (CYP1A2 inhibitor), severe hepatic impairment. Avoid benzodiazepines and Z-drugs in elderly (fall risk, delirium — Beers Criteria)

4. Constipation

Tier	Medication	Contraindications / Cautions
First-Line	Polyethylene glycol (MiraLAX) 17 g PO daily or senna 8.6–17.2 mg PO at bedtime	Both: bowel obstruction, acute abdomen, suspected perforation. Senna: avoid long-term use (melanosis coli, electrolyte derangement)
Second-Line	Bisacodyl 10 mg PO/PR or docusate 100 mg PO BID	Bisacodyl: acute abdomen, bowel obstruction, severe dehydration. Docusate: minimal efficacy as monotherapy — not recommended as sole agent
Third-Line	Lactulose 15–30 mL PO or magnesium citrate; for opioid-induced: methylnaltrexone	Lactulose: galactosemia, bloating/cramping. Magnesium: avoid in renal insufficiency (hypermagnesemia risk — CrCl <30). Methylnaltrexone: known/suspected GI obstruction (risk of perforation)

5. Fever / Mild Pain

Tier	Medication	Contraindications / Cautions
First-Line	Acetaminophen 650–1000 mg PO/IV q6h	Severe liver disease (max 2 g/day in cirrhosis); caution in immunocompromised patients (may mask fever and delay diagnosis)
Second-Line	Ibuprofen 400 mg PO q6h	Renal insufficiency, GI bleeding, heart failure, anticoagulation, cirrhosis (hepatorenal risk), thrombocytopenia
Third-Line	Cooling measures; address underlying cause	N/A — focus on identifying etiology (blood cultures, UA, CXR as indicated) rather than additional antipyretics

6. Pruritus

Tier	Medication	Contraindications / Cautions
First-Line	Topical emollients + cetirizine 10 mg or loratadine 10 mg PO (if histamine-mediated)	Second-gen antihistamines: minimal sedation; rare QTc prolongation at high doses. Avoid diphenhydramine in elderly (fall/delirium risk — Beers Criteria)
Second-Line	Hydroxyzine 25 mg PO q6–8h (if non-elderly, sedation acceptable)	Sedation, anticholinergic effects (dry mouth, urinary retention, constipation); avoid in elderly, dementia, delirium risk, narrow-angle glaucoma
Third-Line	Gabapentin 100–300 mg PO at bedtime (uremic/neuropathic itch) or ondansetron 4 mg IV (opioid-induced pruritus)	Gabapentin: sedation, dizziness, dose-adjust for renal impairment (CrCl <60); respiratory depression risk with opioids. Ondansetron: QTc prolongation, constipation

7. Agitation / Delirium

Tier	Medication	Contraindications / Cautions
First-Line	Nonpharmacologic (reorientation, reduce stimuli, address pain/urinary retention/constipation, mobilize, avoid restraints)	N/A — always the first step; antipsychotics have not been shown to reduce delirium duration or severity (NEJM MIND-USA)
Second-Line	Haloperidol 0.5–1 mg PO/IV (low dose)	QTc prolongation (obtain ECG — hold if QTc >500 ms), Parkinson disease, Lewy body dementia (severe sensitivity reactions), NMS risk, hypokalemia/hypomagnesemia
Third-Line	Olanzapine 2.5–5 mg PO/IM or quetiapine 12.5–25 mg PO	Olanzapine: avoid with concurrent benzodiazepines (respiratory depression), diabetes (hyperglycemia). Quetiapine: orthostatic hypotension, sedation. All antipsychotics: avoid in Parkinson/Lewy body disease; FDA black box warning for increased mortality in elderly with dementia. Reserve benzodiazepines for alcohol/benzo withdrawal only

8. Elevated Blood Pressure (Asymptomatic)

Tier	Intervention	Contraindications / Cautions
First-Line	Repeat measurement; address pain, anxiety, urinary retention, missed home meds. Restart home oral antihypertensives	Avoid PRN IV antihypertensives for asymptomatic elevated BP — per ACC/AHA 2017, defer IV therapy unless acute end-organ damage present
Second-Line	If persistently >180/120 without end-organ damage: amlodipine 5 mg PO or clonidine 0.1 mg PO	Amlodipine: peripheral edema, avoid in severe aortic stenosis. Clonidine: rebound hypertension if stopped abruptly, sedation, bradycardia, AV block; avoid in elderly if possible
Third-Line	Hydralazine 10–25 mg IV (only if symptomatic or concern for end-organ damage)	Reflex tachycardia, headache; avoid in aortic dissection, acute coronary syndrome, tachyarrhythmias

For hypertensive emergency management (IV nicardipine, labetalol, nitroprusside protocols) see Hypertension.

9. Hyperglycemia (BG >180 mg/dL)

Tier	Intervention	Contraindications / Cautions
First-Line	Correction-dose rapid-acting insulin (lispro/aspart per sliding scale) + ensure basal insulin is ordered	Hypoglycemia risk — reduce dose if CKD (reduced insulin clearance), NPO, or recent hypoglycemic episode. Avoid sole reliance on sliding scale without basal insulin (ADA)
Second-Line	Adjust basal insulin (increase by 10–20% if persistent hyperglycemia)	Hypoglycemia, especially overnight; target 100–180 mg/dL for non-ICU patients. Hold or reduce if patient is NPO or has declining oral intake
Third-Line	IV insulin infusion (if critically ill or refractory)	Requires ICU-level monitoring with hourly BG checks; target 140–180 mg/dL in ICU (Surviving Sepsis). Risk of severe hypoglycemia and hypokalemia — monitor potassium

10. Hypoglycemia (BG <70 mg/dL)

Tier	Intervention	Contraindications / Cautions
First-Line	15–20 g fast-acting glucose PO (juice, glucose tabs) if alert; recheck in 15 min	Requires patient to be alert and able to swallow safely; not appropriate if NPO for procedure or altered mental status
Second-Line	Dextrose 50% (D50) 25 mL IV push if unable to take PO or BG <54 mg/dL	Extravasation risk (tissue necrosis) — use large-bore IV in well-functioning line; may cause rebound hyperglycemia; hyperosmolar
Third-Line	Glucagon 1 mg IM/SC if no IV access	Nausea/vomiting common; less effective in hepatic failure, chronic alcohol use, adrenal insufficiency (depleted glycogen stores); transient hyperglycemia followed by rebound hypoglycemia possible

11. Urinary Retention

Tier	Intervention	Contraindications / Cautions
First-Line	Bladder scan; if ≥300 mL (symptomatic) or ≥500 mL (asymptomatic): straight catheterization	Urethral trauma risk — use smallest catheter; avoid urethral catheter if suspected urethral injury (blood at meatus, perineal hematoma); use coude tip if standard fails
Second-Line	Indwelling (Foley) catheter if recurrent retention or large volume (>1 L)	CAUTI risk increases with duration — remove as soon as possible; daily reassessment for removal; avoid in patients who can perform intermittent self-catheterization
Third-Line	Tamsulosin 0.4 mg PO daily (for BPH-related retention) + trial without catheter at 48–72 h	Orthostatic hypotension, dizziness, retrograde ejaculation; intraoperative floppy iris syndrome if cataract surgery planned — document for ophthalmology

12. Back Pain (Acute, Non-Emergent)

Tier	Medication	Contraindications / Cautions
First-Line	NSAIDs (ibuprofen 400 mg PO q6h) or acetaminophen 1 g PO q6h	NSAIDs: renal insufficiency, GI bleeding, heart failure, anticoagulation, third-trimester pregnancy. Acetaminophen: severe liver disease
Second-Line	Cyclobenzaprine 5–10 mg PO TID or methocarbamol 750–1500 mg PO QID	Cyclobenzaprine: sedation, anticholinergic effects, avoid in elderly (Beers Criteria), serotonin syndrome risk with SSRIs/MAOIs, avoid within 14 days of MAOIs, arrhythmia risk. Methocarbamol: sedation, dizziness, avoid with CNS depressants
Third-Line	Heat therapy + consider tizanidine 2–4 mg PO TID	Tizanidine: hepatotoxicity (check LFTs), hypotension, sedation; contraindicated with CYP1A2 inhibitors (ciprofloxacin, fluvoxamine). Opioids not recommended for routine acute low back pain (ACP guideline)

13. Acute Alcohol Withdrawal

Mild Withdrawal (CIWA-Ar <10)

Tier	Medication	Contraindications / Cautions
First-Line	Supportive care ± lorazepam 1–2 mg PO/IV q4–6h PRN (symptom-triggered) or chlordiazepoxide 25–50 mg PO q6h	Benzodiazepines: respiratory depression risk with concurrent opioids/CNS depressants; over-sedation in elderly; risk of precipitating hepatic encephalopathy in advanced liver disease
Second-Line	Gabapentin 300–600 mg PO TID or carbamazepine 200 mg PO TID	Gabapentin: renal dose adjustment, sedation, dizziness. Carbamazepine: hepatotoxicity, bone marrow suppression (obtain CBC), hyponatremia (SIADH), drug interactions (CYP3A4 inducer); avoid in liver disease or childbearing potential without contraception
Third-Line	Phenobarbital 65–130 mg PO/IV (only by experienced clinicians)	Narrow therapeutic window; respiratory depression; over-sedation; bradycardia, hypotension; avoid with concurrent CNS depressants or alcohol; Stevens-Johnson syndrome (rare). Parenteral use only in highly supervised settings (ICU/ED)

Moderate Withdrawal (CIWA-Ar 10–18)

Tier	Medication	Contraindications / Cautions
First-Line	Lorazepam 2–4 mg PO/IV q1–2h (symptom-triggered) or diazepam 5–10 mg PO/IV q1–2h	Lorazepam/oxazepam preferred in advanced liver disease (no active metabolites). Diazepam: avoid in severe hepatic impairment (active metabolites accumulate → encephalopathy risk); respiratory depression with concurrent opioids
Second-Line	Gabapentin or carbamazepine as adjunct; or valproic acid 250–500 mg PO TID as adjunct	Valproic acid: contraindicated in liver disease and childbearing potential (teratogenicity); hepatotoxicity, pancreatitis, thrombocytopenia. Same gabapentin/carbamazepine cautions as above
Third-Line	Phenobarbital as adjunct or alternative (if benzodiazepine-contraindicated)	Same phenobarbital cautions as above. Phenobarbital monotherapy may be associated with lower seizure risk and delirium tremens vs. benzodiazepines, but higher ICU admission rates

Severe Withdrawal (CIWA-Ar ≥19) / Delirium Tremens

Tier	Medication	Contraindications / Cautions
First-Line	Diazepam 10–20 mg IV q10–15 min (front-loading) or lorazepam 2–4 mg IV q10–15 min until calm	Front-loading with diazepam/chlordiazepoxide preferred (ASAM). Monitor for respiratory depression — have flumazenil available. Lorazepam preferred if liver disease. Very large doses may be needed
Second-Line	Phenobarbital 10 mg/kg IV in 100 mL NS over 30 min (adjunct to benzodiazepines)	Requires ICU-level monitoring; respiratory depression, hypotension, over-sedation. Only by experienced clinicians
Third-Line (ICU)	Dexmedetomidine IV infusion or midazolam IV infusion (for benzodiazepine-resistant withdrawal)	Dexmedetomidine: bradycardia, hypotension; does NOT prevent seizures — must be used with a GABAergic agent. Midazolam: respiratory depression, requires intubation readiness. Propofol may also be considered in refractory cases

Adjunctive Medications (All Severity Levels)

Medication	Role	Contraindications / Cautions
Thiamine 200–500 mg IV TID × 3–5 days (then 100 mg PO daily)	Prevent Wernicke’s encephalopathy — give BEFORE glucose	Rare anaphylaxis with IV (have epinephrine available); no significant contraindications
Clonidine 0.1–0.2 mg PO q6–8h	Adjunct for autonomic hyperactivity (tachycardia, hypertension, diaphoresis) not controlled by benzodiazepines	Does NOT prevent seizures or delirium — never use as monotherapy. Rebound hypertension if stopped abruptly; sedation, bradycardia
Folate 1 mg PO daily + multivitamin + electrolyte repletion (Mg²⁺, K⁺, PO₄³⁻)	Nutritional support	Monitor magnesium (hypomagnesemia common and lowers seizure threshold); correct hypokalemia

Management approach per the ASAM Clinical Practice Guideline on Alcohol Withdrawal Management.

14. Chest Pain (Overnight Page)

Step 1: Immediate Workup (Before Any Medications)

12-lead ECG within 10 minutes — compare to prior (2021 AHA/ACC Chest Pain Guideline)
Troponin (hs-cTn preferred); repeat at 1–2 hours if hs-cTn, or 3–6 hours if conventional (2021 AHA/ACC Chest Pain Guideline)
Vital signs including SpO₂, bilateral BP if aortic dissection suspected
Focused history: quality, radiation, pleuritic vs. exertional, associated symptoms (dyspnea, diaphoresis), recent PDE5 inhibitor use
CXR (portable if unstable)
Consider: D-dimer (if PE suspected), BMP, CBC

Step 2: If ACS Suspected (Ischemic ECG Changes, Elevated Troponin, or High Clinical Suspicion)

Tier	Medication	Contraindications / Cautions
First-Line	Aspirin 325 mg chewable STAT (if not already on), then 81 mg daily	Active GI bleeding, true aspirin allergy (anaphylaxis), severe thrombocytopenia, active intracranial hemorrhage
First-Line	Nitroglycerin 0.4 mg SL q5 min × 3 doses	SBP <90 mmHg, recent PDE5 inhibitor use (sildenafil/vardenafil within 24h, tadalafil within 48h, avanafil within 12h), suspected RV infarction (inferior STEMI), severe aortic stenosis, hypertrophic cardiomyopathy with obstruction
First-Line	Heparin (UFH bolus + infusion or enoxaparin 1 mg/kg SC q12h) once ACS confirmed	Active bleeding, HIT history (for UFH), severe thrombocytopenia, recent major surgery/trauma. Enoxaparin: dose-adjust for CrCl <30 mL/min
Second-Line	Beta-blocker (metoprolol 25 mg PO) within first 24h	Acute heart failure, cardiogenic shock, SBP <100, HR <60, second/third-degree AV block, severe reactive airway disease, cocaine/methamphetamine use (risk of unopposed alpha stimulation)
Second-Line	P2Y₁₂ inhibitor (ticagrelor 180 mg loading or clopidogrel 300–600 mg) — typically after cardiology consultation	Active bleeding, prior intracranial hemorrhage; ticagrelor: avoid with strong CYP3A4 inhibitors, maintenance aspirin >100 mg/day reduces efficacy; clopidogrel: CYP2C19 poor metabolizers (reduced efficacy). Timing depends on invasive vs. conservative strategy
Third-Line	Morphine 2–4 mg IV or fentanyl 25–50 µg IV (for pain refractory to nitrates)	Hypotension, respiratory depression; morphine may delay absorption of oral P2Y₁₂ inhibitors; use only when anti-ischemic therapy is maximized. Naloxone should be available

Step 3: If Non-Cardiac Chest Pain Suspected (Normal ECG, Negative Troponins, Low Clinical Suspicion)

Suspected Etiology	First-Line	Contraindications / Cautions	Second-Line
GERD / Esophageal	PPI (pantoprazole 40 mg IV/PO) + antacid	Viscous lidocaine: aspiration risk if swallowing impaired; anticholinergic effects	GI cocktail (antacid + viscous lidocaine + anticholinergic)
Musculoskeletal / Costochondritis	Acetaminophen 1 g PO q6h or ibuprofen 400 mg PO q6h	Minimal systemic absorption; avoid on broken skin	Topical diclofenac or ice/heat
Pleuritic (pneumonia, pleuritis)	Acetaminophen for pain + treat underlying cause	Avoid if renal insufficiency, GI bleeding risk, or ACS not excluded	NSAIDs (ibuprofen 400–600 mg PO q6h) for pleurisy
Anxiety / Panic	Reassurance + nonpharmacologic after cardiac causes excluded	Sedation, respiratory depression, fall risk in elderly; avoid if substance use disorder	Lorazepam 0.5–1 mg PO (short-term, if severe)

Key Principles for Chest Pain Pages

Never attribute chest pain to a benign cause without an ECG and troponin (2021 AHA/ACC Chest Pain Guideline).
Do not give nitroglycerin without checking for recent PDE5 inhibitor use, SBP, and signs of RV infarction.
NSAIDs (except aspirin) should be discontinued in patients with confirmed or suspected ACS (2025 ACC/AHA ACS Guideline).
Activate the STEMI protocol immediately if ST elevation is present — do not delay for additional workup.
Notify the primary team and/or cardiology for any new troponin elevation, ischemic ECG changes, or hemodynamic instability.