Havard's Nursing Guide to Drugs 9e by Adriana Tiziani
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Havard's Nursing Guide to Drugs 9e by Adriana Tiziani



A bestselling Elsevier textbook, Havard’s Nursing Guide to Drugs has been the premier drug guide for nurses and midwives since 1983. ...

A bestselling Elsevier textbook, Havard’s Nursing Guide to Drugs has been the premier drug guide for nurses and midwives since 1983.

This ninth edition of Havard’s Nursing Guide to Drugs continues to provide reliable, accurate drug information for nursing and midwifery students and practitioners. All content in this musthave
nursing drug handbook, is tailored for nurses and midwives in Australia and New Zealand.

User-friendly and fully up-to-date, this indispensible nursing textbook delivers safe drug administration information regarding form, action, use, dose, adverse effects and interactions in compliance with current pharmaceutical guidelines by the Therapeutic Goods Association (TGA).

Each therapeutic drug class features a detailed description, followed by an A-Z of drugs within that class.

Important Nursing points and cautions throughout this edition highlight best practice in drug administration. Patient teaching and advice has been included to emphasise an essential part of
care within a multidisciplinary team.

This edition also features icons that indicate drug cautions during pregnancy and breastfeeding, and another that indicates drug-specific restrictions in sport.
For more information visit: http://www.elsevierhealth.com.au/general-nursing/havard-nursing-guide-to-drugs-paperbound/9780729541411/



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    Havard's Nursing Guide to Drugs 9e by Adriana Tiziani Havard's Nursing Guide to Drugs 9e by Adriana Tiziani Document Transcript

    • 9th editionAdriana TizianiHAVARD’STO DRUGSNURSINGGUIDESample chapter
    • Mosbyis an imprint of ElsevierElsevier Australia. ACN 001 002 357(a division of Reed International Books Australia Pty Ltd)Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067© 2013 Elsevier AustraliaThis publication is copyright. Except as expressly provided in the Copyright Act 1968and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publicationmay be reproduced, stored in any retrieval system or transmitted by any means (includingelectronic, mechanical, microcopying, photocopying, recording or otherwise) without priorwritten permission from the publisher.Every attempt has been made to trace and acknowledge copyright, but in some casesthis may not have been possible. The publisher apologises for any accidental infringementand would welcome any information to redress the situation.This publication has been carefully reviewed and checked to ensure that the content is asaccurate and current as possible at time of publication. We would recommend, however, thatthe reader verify any procedures, treatments, drug dosages or legal content described in thisbook. Neither the author, the contributors, nor the publisher assume any liability for injuryand/or damage to persons or property arising from any error in or omission from this publication.National Library of Australia Cataloguing-in-Publication Data___________________________________________________________________Tiziani, Adriana, author.Havard’s nursing guide to drugs / Adriana Tiziani.9th edition9780729541411 (paperback)Nursing—Handbooks, manuals, etc.Drugs—Handbooks, manuals, etc.615.1___________________________________________________________________Publishing Director: Luisa CecottiPublisher: Libby HoustonDevelopmental Editor: Elizabeth CoadyProject Manager: Liz MalcolmEdited by Margaret TrudgeonTechnical editing by Jerry Perkins BSc, BPharm and Lynne MacKinnon BPharmProofread by Tim LearnerIndexed by Robert SwansonCover and internal design by Darben DesignsTypeset by Midlands Typesetters, AustraliaPrinted in China by China Translation and Printing ServicesSample chapter
    • CONTENTS BY THERAPEUTIC CLASSPreface viiIntroduction ixAt a glance xxivPatient teaching and advice xxvAnalgesics, non-steroidal anti-inflammatory drugs (NSAIDs)and disease-modifyingantirheumatic drugs (DMARDs) 1Anorectics and weight-loss agents 43Antacids 46Anthelmintics 48Anti-Alzheimer’s agents 54Antianginal agents 59Antianxiety agents 72Antiarrhythmic agents 80Antiasthma agents andbronchodilators 94Antibacterial agents 119Anticoagulant andantithrombotic agents 180Antidepressants 201Antidiabetic agents 223Antidiarrhoeal agents 247Antidotes, antagonists andchelating agents 250Antiemetic agents 278Antiepileptics 291Antifungal agents 316Antigout and uricolytic agents 339Antihistamines 346Antihypertensive agents 355Antimalarial agents 394Antimigraine agents 404Antimycobacterial agents 417Antineoplastic agents 430Antineoplastic support agents 484Anti-Parkinson’s agents 490Antiplatelet agents 509Antiprotozoal agents 521Antipsychotic agents 528Antiulcer agents 556Antiviral agents 567Bladder function disorder agents 605Bone- and calcium-regulatingagents 616Cardiac glycosides 634Cholinergic and anticholinergicagents 639Corticosteroids 648Cough suppressants, expectorantsand mucolytics 661Dermatological agents 667Diuretics 692Drug dependence 711Erectile dysfunction agents 723Eye, ear, nose and throat agents 729Fibrinolytic agents 774Gastrointestinal agents(miscellaneous) 780General anaesthetics 788Haemopoietic agents 797Haemostatics 804Hypothalamic and pituitaryhormones 816Immunomodifiers 837Laxatives 876Lipid-regulating agents 887Local anaesthetics 899Muscle relaxants 907Neuromuscular-blocking agents 914Opioid analgesics 922Pregnancy, childbirth andbreastfeeding 937Sedatives and hypnotics 963Sex hormones 973Stimulants 1003Sympathomimetic agents 1011Thyroid and antithyroid agents 1022Topical rectal medication 1031Vaccines, immunoglobulins andantivenoms 1034Vasodilators 1062Sample chapter
    • ivHAVARD’S NURSING GUIDE TO DRUGSVitamins, minerals andelectrolytes 1070Miscellaneous agents 1099Appendix 1: Poisoning and itstreatment 1118Appendix 2: Poisons informationcentres and medicine informationcentres 1122Appendix 3: Alternative drugnames 1124Appendix 4: Normal referencevalues 1125Bibliography 1137Glossary 1143Index 1149Sample chapter
    • CONTENTS BY BODY SYSTEMCARDIOVASCULAR SYSTEMAntianginal agents 59Antiarrhythmic agents 80Anticoagulant and antithromboticagents 180Antihypertensive agents 355Antimigraine agents 404Antiplatelet agents 509Cardiac glycosides 634Diuretics 692Fibrinolytic agents 774Haemopoietic agents 797Haemostatics 804Lipid-regulating agents 887Sympathomimetic agents 1011Vasodilators 1062CENTRAL AND PERIPHERAL NERVOUSSYMPTOMSAnti-Alzheimer’s agents 54Antianxiety agents 72Antidepressants 201Antiemetic agents 278Antiepileptics 291Anti-Parkinson’s agents 490Antipsychotic agents 528Cholinergic and anticholinergicagents 639Drug dependence 711General anaesthetics 788Local anaesthetics 899Opioid analgesics 922Sedatives and hypnotics 963Stimulants 1003RESPIRATORY SYSTEMAntiasthma agents andbronchodilators 94Cough suppressants, expectorantsand mucolytics 661DIGESTIVE SYSTEM, METABOLISM ANDNUTRITIONAnorectics and weight-loss agents 43Antacids 46Antidiarrhoeal agents 247Antiemetic agents 278Antiulcer agents 556Cholinergic and anticholinergicagents 639Gastrointestinal agents(miscellaneous) 780Laxatives 876Topical rectal medication 1031Vitamins, minerals andelectrolytes 1070MUSCULOSKELETAL SYSTEMAnalgesics, non-steroidal anti-inflammatory drugs (NSAIDs)and disease-modifyingantirheumatic drugs(DMARDs) 1Antigout and uricolytic agents 339Cholinergic and anticholinergicagents 639Muscle relaxants 907Neuromuscular-blocking agents 914ENDOCRINE SYSTEMAntidiabetic agents 223Bone- and calcium-regulatingagents 616Corticosteroids 648Hypothalamic and pituitaryhormones 816Thyroid and antithyroid agents 1022URINARY SYSTEMBladder function disorder agents 605Cholinergic and anticholinergicagents 639Diuretics 692REPRODUCTIVE SYSTEMErectile dysfunction agents 723Pregnancy, childbirth andbreastfeeding 937Sex hormones 973Sample chapter
    • viHAVARD’S NURSING GUIDE TO DRUGSINTEGUMENTARY SYSTEMDermatological agents 667IMMUNE SYSTEMAntihistamines 346Antineoplastic agents 430Antineoplastic support agents 484Corticosteroids 648Immunomodifiers 837Vaccines, immunoglobulins andantivenoms 1034SPECIAL SENSESEye, ear, nose and throat agents 729INFECTION AND INFESTATIONSAnthelmintics 48Antibacterial agents 119Antifungal agents 316Antimalarial agents 394Antimycobacterial agents 417Antiprotozoal agents 521Antiviral agents 567MISCELLANEOUSAntidotes, antagonists andchelating agents 250Miscellaneous agents 1099Sample chapter
    • PrefaceThis is the 30th anniversary of the original Havard’s Nursing Guide to Drugs, thensimply called Nursing Guide to Drugs, written by Margaret Havard. Margaret was anurse educator and colleague who had worked for many years with hospital-trainednurses teaching pharmacology. Margaret’s recognition of a need for an Australianbook that would give nurses a guide to safe administration of medications to theirpatients gave her the impetus to write the first edition. Little did she imagine that 30years later this book would still be in production and being used in all types of patientsettings. This book is dedicated to Margaret.As with the original aim of the book, Havard’s Nursing Guide to Drugs continuesto be a guide only. This book is meant to be a companion guide to pharmacologytexts, something smaller and easier to transport around and reference in the clinicalsituation, especially now that it is available in electronic form as well. As with previouseditions, each drug has been reviewed to ensure it is still relevant to the healthcaresetting, with old and obsolete drugs deleted and new drugs (or old drugs with newuses) added. New to this edition is an expanded ‘Patient teaching and advice’ sectionwhich highlights key points for teaching purposes.Sample chapter
    • Sample chapter
    • ixINTRODUCTIONTHE NURSE’S ROLE IN DRUG THERAPYThe aims of administering medicationare to do it safely and efficiently and toobserve the patient for both desirableand undesirable effects. Therefore thenurse needs to:● assess the patient, including medica-tion history● have an understanding of the legalrequirements associated with the ad-ministration of drugs● have pharmacological knowledge ofthe medication(s)● be able to safely administer medica-tions.ASSESSING THE PATIENTPatient assessment should be holistic,looking at the patient’s condition andpersonal circumstances as a whole, rath-er than simply as a disease to be treated.It should include:● all current medical problems● co-morbidities● relevant past history● physical assessment● medication history (current medica-tions, over-the-counter preparations,herbal preparations, vitamin andmineral supplements).Medical history, co-morbidities andmedication history are intertwined asa person with multiple co-morbiditiesoften being prescribed multiple medi-cations simultaneously (polypharmacy)increasing the risk of adverse effects andinteractions. A person may see morethan one medical practitioner (e.g. gen-eral practitioner (GP) plus a numberof specialists) and they may not alwaysreview previous or current medications.Having prescriptions filled in multiplepharmacies may also be problematic asthere is no on-going record of medica-tions (and hence the possibility of thesame prescription being filled multipletimes using different brands).People may become confused be-cause medication can have more thanone brand/trade name for the same ge-neric drug and potentially end up tak-ing the same drug twice (e.g. a patienttaking Urex and Lasix (both trade namesfor frusemide) may become quickly de-hydrated).Unfortunately, people do not alwayscomplete courses of medications, espe-cially antibiotics, and ‘keep the rest fornext time’ with no understanding of theramifications of doing this (e.g. bacteriabecoming resistant to that antibiotic andthe agent becoming ineffective in treat-ing that same infection if it recurs).Some people believe they are allergicto medications. It is important for thenurse to explore what form the supposedallergy takes (e.g. someone may mistak-enly believe that he/she is allergic tomorphine because he/she was nauseousand vomited after taking it (a commonside-effect), whereas another patientmay correctly describe an anaphylacticreaction with breathing difficulties afteradministration of an antibiotic).Many people also take over-the-counter (OTC) preparations or alter-native medicines, including herbalpreparations, either concurrently orinstead of traditional medication. OTCpreparations are those that are non-prescription and are generally intendedSample chapter
    • xHAVARD’S NURSING GUIDE TO DRUGSfor short-term use only in self-limitingillnesses such as headache, heartburnand constipation. OTCs also include vi-tamins, minerals and herbal drugs andremedies (e.g. St John’s wort, ginseng)and unfortunately, many people con-sider them to be ‘safe’ because they arenatural. However, many herbal drugsand remedies interact with prescrip-tion medications (e.g. St John’s wortinteracts with warfarin increasing itsmetabolism and decreasing its effective-ness); antacids can interfere with someoral medications if not taken 2 hoursapart; and non-prescription medicationssuch as aspirin and ibuprofen can causegastrointestinal bleeding and must onlybe taken at recommended doses. OTCsare readily available in pharmacies andsupermarkets, with the buyer not need-ing to seek advice before purchasingthese products.It is essential for the nurse to estab-lish if the patient is compliant/adherent/concordant with his or her medicationregimen, and if not, why not. While theseterms are sometimes used interchange-ably, they do have some important dif-ferences. Compliance suggests thatthe patient has little input into his/hermanagement strategy and follows doc-tor’s orders (power lies with the doctor),while concordance is at the other endof the spectrum, and is based on equal-ity and respect between the patient andthe health care practitioner. Adherencefalls somewhere in between as there isnegotiation between the patient and thehealth care professional which is basedaround the therapy (e.g. asthma manage-ment plan) (National Asthma Council,2005). One Australian study looking atthe use of antihypertensive medicationsfound that 19% of people failed to have asecond prescription filled. Furthermore,people persisted with their antihyper-tensive medications on average for only20 months (Simons, Ortiz and Calcino,2008).Adherence is a very complex issue.Some of the factors that may lead to apatient not being adherent with a medi-cation regimen may include:● multiple medications● complex dosing schedules (a personis more likely to remember a once-daily dosing schedule, compared to a3–4 times daily regimen)● medication difficult to take or admin-ister (e.g. medications that have anunpleasant taste or are large in size;eye and ear drops that are difficult toinstil)● impairments including:— sight (e.g. unable to read direc-tions)— dexterity (e.g. arthritis) may makeit difficult to open containers withchildproof lids or blister packs, or— memory (e.g. unable to remem-ber instructions of how or whento take medication)— adverse effects (i.e. the person maydecide that the side-effects of themedications are worse than thedisease itself)— feeling ‘better’ and therefore notneeding to take the medicationany longer— not ‘seeing’ any effects from themedication (e.g. effects of lipid-lowering agents are not visible andthese are commonly discontinuedby patients)— cost and ease of filling prescrip-tions (e.g. decreased mobility orlack of transport to be able to goto the pharmacy)Sample chapter
    • xiINTRODUCTION— lack of knowledge/understandingof the disease process and the roleof medication in disease manage-ment— attitude towards medication, dis-ease and/or health (e.g. a ‘devilmay care’ attitude or thoughtssuch as ‘I have to die of some-thing’)— inconsistency in the messagesthat health providers are giving(e.g. one nurse advises the patientto take certain medications 30–60minutes before food, while anoth-er nurse says that it doesn’t matterwhen the medication is taken).Not only are these inconsistentmessages confusing for the patientbut they also damage the trust thepatient may have in the nurse(s),as well as potentially affecting theabsorption and effectiveness of themedication.Armed with all this information, thenurse is in an ideal position to supportand educate the patient (see section onPatient teaching and advice).CHILDREN AND THE ELDERLYChildren and the elderly require highlyspecialised nursing care and knowledgeregarding administration of medica-tions. Special care should be taken withdosages because overdose can occur eas-ily due to smaller weights (and surfaceratios), and differences in kidney andliver capacity. There are many special-ised texts available that cover both thesegroups in detail and take into accountthe differences in drug administration.Specific paediatric and geriatric dosagesare not generally included in this book.Doses are for the ‘average’ adult patient.The only exceptions are when a particu-lar drug is mainly or specifically used inpaediatrics (e.g. drugs used for attentiondeficit disorder, growth hormone).Many older people require assistancewith the administration of medicationsand the nurse may consider splitting orcrushing tablets in order to make themeasier to take. Before doing this, investi-gate whether the medication is availablein a different oral form (e.g. liquid ratherthan solid) or a non-oral form (e.g. der-mal, rectal, intranasal). Tablets with anenteric coating should not be crushedas these are formulated to ensure themedication passes through the stomachintact (e.g. enteric aspirin is formulatedto prevent gastric irritation). Extended-release medications (often marked asCD, CR, SA, SR) are designed to releasethe active components over an extend-ed period and therefore should not becrushed. There is further discussion onextended-release medication under Oraladministration.DRUGS IN SPORTThe World Anti-Doping Agency(WADA) was established in 1999 tofoster a doping-free culture in sport by:● conducting scientific research to de-velop new detection methods● educating athletes and support per-sonnel● raising awareness and providing in-formation about doping and its con-sequences● conducting an unannounced out-of-competition testing program thatcomplements the programs of the In-ternational Sports Federations (IFs)● developing an independent observerprogram (which randomly monitorsSample chapter
    • xiiHAVARD’S NURSING GUIDE TO DRUGSand reports on all phases of dopingcontrol in an unbiased manner)● monitoring acceptance and compli-ance with the World Anti-DopingCode, which ensures all athletes inall sports are governed by the sameanti-doping rules and regulations.Groups of drugs or methods prohibitedor restricted by WADA include: anabolicsteroids (e.g. stanozolol, testosterone),peptide hormones (e.g. erythropoietin,insulin, tetracosactrin), growth factorsand related substances (e.g. growth hor-mone), beta-2 adrenoceptor blockingagents (e.g. propranolol), beta-2 agonists(e.g. eformoterol, isoprenaline NOT sal-butamol or salmeterol), hormone antag-onists and modulators (e.g. clomiphene,aminoglutethimide, tamoxifen), diuretics(e.g. frusemide, acetazolamide, thiazidediuretics) and other masking agents (e.g.probenecid), substances enhancing oxy-gen transfer (e.g. haemoglobin products),blood doping (e.g. red blood cell productof any origin) and sample manipulationmethods (e.g. tampering with samples orurine substitution), stimulants (e.g. am-phetamines, adrenaline, pseudoephed-rine), opioids (e.g. heroin, morphine),cannabinoids (e.g. marijuana), glucocor-ticosteroids (e.g. dexamethasone, pred-nisolone) and alcohol.It is imperative that the athlete isaware of substances and methods thatare prohibited at all times, substancesthat are prohibited in-competition andsubstances that are prohibited in particu-lar sports (WADA, 2011).PREGNANCYAny medication (including OTCs, herb-al preparations, alternative therapiesor chemicals such as alcohol) has thepotential to reach the developing fetusvia the maternal circulation if taken dur-ing pregnancy. The risk to the fetus is de-pendentonanumberoffactors,includingfetal gestational age on exposure (i.e. thefetus is most at risk during the first tri-mester when cells are rapidly proliferatingandorgans,muscles,CNS,arms,legs,toesand fingers are developing), duration oftherapy (including dose, frequency andlength of therapy), as well as any othermedication taken concurrently (Bryant& Knights, 2011). Animal studies haveshown considerable differences in species’response with regard to the teratogeniceffects of drugs and it may not be possibleto extrapolate this data to humans. Fetalabnormalities include missing digits,excessive development or duplication ofparts, splitting of parts abnormally, non-splitting of parts, fusion failure or over-fusion of some parts, openings failing toclose or open adequately or abnormalplacement of parts.Generally, medications should beavoided during pregnancy if possible.However, this is not always practicable.The woman who is pregnant (or consid-ering pregnancy) should work in partner-ship with her medical practitioner to de-velop a medication regimen that balancesthe benefits to the mother against thepotential risks to the fetus. For example,a woman with epilepsy may need to con-sider the potentially life-threatening risksassociated with uncontrolled epilepsyversus the benefits of controlling epilepsywith an agent that has an increased risk ofcausing fetal abnormalities.LACTATIONMost drugs taken by a mother who isbreastfeeding will be excreted to someSample chapter
    • xiiiINTRODUCTIONextent in the breast milk; however, theamount ingested by the infant will gener-ally be extremely small but is dependenton the age of the infant and the amountof breast milk consumed.However, some drugs are concen-trated in breast milk relative to the ma-ternal plasma concentration because oftheir chemical properties, including fatsolubility and may be toxic to the infantbecause of immaturity of the liver andkidney detoxification systems (Bryant &Knights, 2011).Administering the drug when or im-mediately after the infant feeds will resultin the lowest amount of drug in the milkat subsequent feedings. If a drug is es-sential for the mother, but of uncertaineffect on the infant, it may be necessaryto temporarily discontinue breastfeed-ing and remove contaminated breastmilk (via breast pump) which shouldbe discarded. Medications that shouldbe avoided during breastfeeding includeamiodarone, chloramphenicol, cocaine,cyclosporin, diazepam, heroin, radio-active iodine, lithium, tetracyclines andtheophylline (Bryant & Knights, 2011).If medication is taken during breast-feeding, the infant should always beclosely observed for any side-effects, in-cluding poor feeding, listlessness, with-drawal symptoms and other abnormalbehaviours that should be reported ifthey occur.RENAL AND LIVER IMPAIRMENTDose reduction is often required in thosewith any type of kidney and/or liver im-pairment because these organs are themain sites of drug metabolism and ex-cretion. Monitoring of kidney and liverfunction throughout any drug therapymay be recommended to ensure thatthere is no further deterioration causedby the drug therapy. Furthermore, somemedication may damage the liver or kid-neys (e.g. large doses of paracetamol arehepatotoxic, NSAIDs may be nephrotox-ic). If potentially nephrotoxic or hepato-toxic agents are given to those with renalor liver impairment, the risk of furtherdamage is greatly increased.LEGAL REQUIREMENTSBefore a drug can be administered safely,the nurse needs to be aware of the legalaspects of drug administrations. This in-cludes knowledge of the laws governingthe possession, use and dispensation ofdrugs and of the directives of the nurse’sregistering body on the administrationof medications to clients. It also meansobserving the employing health carefacility’s occupational health and safety(OHS) regulations that are designed topromote safe storage, handling and useof drugs.The Nursing and Midwifery Boardof Australia (NMBA) is one of the na-tional boards of the Australian HealthPractitioner Regulation Agency (AH-PRA). With the changes to registrationof nurses by AHPRA from 2010, it wasdecided that enrolled nurses no longerrequired endorsement for medicationadministration. The NMBA’s goal is forall enrolled nurses to undertake relevantunits of study that will enable them toadminister medicines safely as part oftheir education program. However, forenrolled nurses who have not completedthe required units, a notation reading‘Does not hold Board-approved qualifi-cations in administration of medicines’will appear on the national nursing reg-ister against that nurse’s name (NMBA,2010). Jurisdictional legislation andSample chapter
    • xivHAVARD’S NURSING GUIDE TO DRUGSpolicy specifies the routes and schedulesof medicines that the enrolled nurse isable to administer and it is therefore ofparamount importance that the nurseand employer understand and complywith the drugs and poisons legislationand policy. Furthermore, to administerintravenous medication, the enrollednurse (Division 2) is required to havecompleted a separate NMBA-approvedunit on the administration and monitor-ing of intravenous medications (NMBA,2010).Legal Acts concerning poisons andthe poisons regulatory bodies in NewZealand and each state and territoryin Australia deal with the control of alldrugs, from prescription medicationthrough to agricultural poisons and re-search drugs. The laws and regulationsapply to sale, supply, storage, dispensingand labelling. The drugs and poisonsschedules divide drugs into groups ac-cording to their mode of action, thera-peutic use, potency, potential for abuseand addiction and safety. While thereis currently no national medicines andpoisons schedule in Australia, the rec-ommendations of two expert advisorycommittees (Advisory Committee onMedicines Scheduling and AdvisoryCommittee on Chemical Schedul-ing) in the form of the Standard forthe Uniform Scheduling of Medicinesand Poisons (SUSMP, Table 2) are usu-ally incorporated into the legislation andregulations of each state and territory ofAustralia and New Zealand (Austra-lian Government, TGA, 2010). Aims ofthis document include promoting uni-form scheduling, labelling and controlson availability and use of medicinesthroughout Australia and New Zealand(Australian Government, TGA, 2010).The recommendations of SUSMP applyfor all medicines and poisons in Austra-lia and medicines in Schedules 2, 3 and4 in New Zealand. New Zealand specificlegislation exists for medicines which falloutside these schedules.Nurse practitioners, as defined bythe Nurses Act 1993, are those whoseregistration has been endorsed as be-ing qualified to obtain and have in her/his possession and to use, sell or sup-ply Schedule 2, 3, 4 or 8 poisons, as de-scribed under the Drugs, Poisons andControlled Substances Act 1981 (VersionNo. 065, 1/12/2003).STORAGEAll medications in a ward or departmentshould be kept in a locked cupboard,medication trolley or some other type oflocked container, the key of which is keptby a nurse at all times. Victoria’s Drugs,Poisons and Controlled Substances Reg-ulations 1995 are very specific about thestorage requirements for Schedule 8 orSchedule 9 poisons (e.g. constructed ofsteel 10 millimetres thick; fitted with a6-lever lock; able to resist attack by handtools for 30 minutes or power tools for 5minutes) with other states having similarrequirements.Drugs or preparations for externaluse should be stored apart from thoseintended for internal use, so that errorsin administration do not occur. Sup-positories, pessaries, insulins, antisera,vaccines, some blood products, some in-travenous solutions and some antibiotics(particularly if reconstituted) should bestored in the refrigerator. Nothing elseshould be stored in the refrigerator (e.g.food) and it should also be kept locked.The trend towards single-dose unitsbeing dispensed contributes to accuracySample chapter
    • xvINTRODUCTIONin dosage, better economy and less riskof product contamination. Many insti-tutions have policies that discourage theuse of multi-dose vials because of therisk of cross-contamination betweenpatients.DRUG ORDERSIn 2004 the Australian health ministersadvised that ‘to reduce the harm to pa-tients from medication errors, by June2006, all public hospitals will be using acommon medication chart. This meansthat the same chart will be used wherevera doctor or nurse works and whereverthe patient is within a hospital’ (AC-SQHC, n.d.). The result was the Nation-al Inpatient Medication Chart (NIMC).Since then there have been additionalnational charts developed, which haveincluded the National Aged Care Resi-dential Medication Chart (NRMC),National Interim Residential Medica-tion Administration Chart (NIRMAC),National Subcutaneous Insulin Chart,Paediatric Medication Chart and PrivateHospital and Private Hospital Day Sur-gery NIMC (ACSQHC, 2012a).A drug or preparation may be givenonly on written or verbal order from amedical officer, and must be clearly writ-ten and/or understood verbally. The lawin all states requires that a legal drug or-der must be legibly written in ink, datedand signed by the prescriber and mustinclude the patient’s name and identifi-cation number (if applicable), the nameand strength of the drug, the dose, routeof administration, frequency of admin-istration and duration of administration(if applicable). Any alteration to a drugorder should be initialled. An unusualdose, drug strength or quantity shouldbe underlined and initialled by theprescriber. If there is any doubt aboutthe meaning of the order, the medicalofficer should be contacted immediatelyfor clarification before administration.The policy of the institution shouldbe consulted before taking telephoneorders for drugs. A telephone ordershould only be taken ‘if in the opinionof the medical practitioner, dentist ornurse practitioner, an emergency ex-ists’ (Drugs, Poisons and ControlledSubstances Regulations 2006, Reg.47, 2 (C)). Errors may be eliminated ifthe nurse ensures that the drug has beenordered for the correct patient, writesit on the correct patient’s medicationchart, then asks a second nurse to readthe drug order back over the telephoneto the medical officer. The order shouldbe confirmed in writing by the prescrib-er as soon ‘as practicable’. However, in-stitutions may have their own policiesthat require their medical officers tosign the order within 24 hours. If anydoubt at all exists (e.g. the patient is un-well and requires reviewing, the nurseis unsure about the drug, dose etc.), thenurse should not take the telephone or-der and should ask the medical officerto review the patient or medication or-der as soon as practicable.LEGAL RESPONSIBILITYFollowing a medical officer’s order wasonce thought by many to absolve thenurse from all responsibility. However,legal judgements have shown that this isnot always the case. The question that isoften asked in situations of a drug erroroccurring is ‘What would the reasonablenurse do in this situation?’Given that administering drugs is aneveryday part of the role of most nurses,it is therefore not an unfair expectationSample chapter
    • xviHAVARD’S NURSING GUIDE TO DRUGSthat they will have some knowledge ofthe drugs they are administering. Thisincludes the class of drug, why it is pre-scribed (purpose), how it works (action),recommended or usual dose range, howit is administered, contraindications,side-effects, potential for causing allergicreactions, any interactions with foods orother drugs and compatibility (especiallywhen multiple intravenous drugs are tobe administered).It is not necessary for the nurse tomemorise all this information; however,what is important is that the nurse hasready access to information and knowswhere or how to readily do so before ad-ministration. Information on any drugor preparation may be obtained from apharmacist, textbooks or reliable inter-net sources. Once in possession of thisknowledge the nurse can question an un-clear order, assess what skills are requiredto carry out the order and will understandwhat to observe in the patient in terms ofbeneficial and adverse effects.DRUG INCIDENTS (ERRORS)Drug incidents (or errors) may occur attheprescribing,dispensingor administer-ing stage of the process. A study by Leape,Bates and Cullen. (1995) found that doc-tors and nurses were responsible for 39%and 38% of errors respectively. Theyfound that the causes of errors includedlack of knowledge. A more recent studyby Nichols, Copeland, Craib et al. (2008)found that added to this lack of knowl-edge other causes of prescribing errorsincluded lack of supervision by seniorcolleagues when prescribing unfamiliarmedications, dealing with unfamiliar pa-tients, working on unfamiliar wards anda lack of communication.Administration incidents (errors)occur when:● the wrong drug is administered, in-cluding the administration of thewrong intravenous fluid (e.g. drugswith similar names; use of abbrevia-tions for names)● the wrong dose is given (e.g. misread-ing dosage or units; misinterpretingabbreviations used for units (e.g. mi-crograms))● the drug is given via the wrong route(e.g. an oral drug given intravenous-ly)● the drug is given to the wrong patient● the drug is given at the wrong time orfrequency, including omission● an intravenous infusion is adminis-tered at the wrong rate.Since 2008, standard prescribing termi-nology, abbreviations and symbols havebeen introduced in an attempt to reducethe number of associated errors. Ab-breviations are used when referring tostrength of medications such as grams(g) and milligrams (mg). For example,the abbreviation for micrograms usingthe Greek letter μ (mu), that is, μg, isnot recommended, nor is mcg, as thesemay lead to errors; microg is the pre-ferred and recommended abbreviation,or the whole word (microgram) shouldbe used. Other error prone abbreviationsand symbols that should be avoided in-clude IU (international units – can bemistaken for IV), IVI (intravenous injec-tion – mistaken for IV 1) and qd (everyday – mistaken as qid (four times daily))(Australian Commission on Safety andQuality in Health Care, 2011).The use of ‘dose administration aids’commonly found in aged care facilitiesmay not necessarily reduce the numberof administration errors. A 2006 studyconducted in New South Wales (Aus-tralia) found that ‘dose administrationSample chapter
    • xviiINTRODUCTIONaids’ contained a significant number oferrors (incident rate 4.3% of packs and12% of residents), which included miss-ing medications, wrong medication orwrong strength of medication dispensed,incorrect dosage instructions suppliedor medications being supplied that hadbeen ceased by a doctor (Carruthers,Naughton & Mallarkey, 2008). Althoughon the surface this would appear to be adispensing and pharmacy-related prob-lem, it is also the responsibility of thenurse administering the medications tohave some idea of what medication a pa-tient has been prescribed (or no longerprescribed) and what the medication(s)actually looks like.An administration error may or maynot have an adverse effect. The serious-ness of the outcome (e.g. the adverse ef-fect or lack of) does not absolve the nursefrom the mistake that was made. It is im-portant to clearly document the error andoutcome. Some institutions may also havepolicies regarding further documentationrequirements when an error has occurred(e.g. a ‘drug incident’ form).It is important for nurses to practisewithin their own limitations and withinthe policies and protocols of the institu-tion. If this is not done and an error oc-curs (especially a serious one), the nursemay find that the institution (and its in-surers) may abrogate any responsibilitybecause the nurse did not follow its poli-cies. The nurse may also be liable undercommon law.A LITTLE PHARMACOKINETICSFor extensive pharmacokinetics, refer topharmacology texts. Here are some basicconcepts that nurses need to understand.Pharmacology is the ‘study of drugs,including their actions and effects onliving systems’ (Bryant & Knights, 2011,p. 2). Pharmacokinetics is the absorption,distribution, metabolism and excretionof these substances, and pharmacody-namics is concerned with the physiologi-cal effects that the substances have on theorganism.Pharmacokinetics and the olderpersonThere are many age-related changes tothe body that affect the way that a drugmay be absorbed, distributed, metabo-lised and excreted. Because of thesedifferences, all drug therapy should begiven cautiously and monitored carefullyin the older patient. Age-related changesthat may affect the pharmacokinetics ofa drug include:● altered nutritional habits and inges-tion of non-prescription drugs (e.g.antacids and laxatives) may affectdrug absorption● changes in the quantity and quality ofdigestive enzymes● increase in gastric pH● decrease in gastric motility● decrease in intestinal blood flow● delayed gastric emptying● decreases in total body water, leanbody mass and increase in body fatmay all lead to an altered distributionof the drug● decreases in plasma proteins, andtherefore decreased protein bindingof drugs, leading to higher levels offree drug (increasing the risk of ad-verse effects and/or toxicity)● the greatest changes appear to be dur-ing Phase I metabolism in the liver,which involves microsomal enzymes● the liver’s ability to recover from in-jury, such as hepatitis, is reduced withageSample chapter
    • xviiiHAVARD’S NURSING GUIDE TO DRUGS● hepatic function may also be affectedby severe nutritional deficiencies● decreased cardiac output and reserve● decreased blood flow to the liver andkidneys● congestive heart failure reduces thecapacity of the liver to metabolisedrugs as well as reducing hepaticblood flow● creatinine clearance decreases withage, resulting in a longer half-life ofmany drugs and the subsequent riskof accumulation (toxicity)● decreased renal excretion.Drug dosageDosage depends on the age, weight, sex,renal and liver function and general con-dition of the patient and can be based onage, body weight or body surface area.As children usually require smaller dosesthan adults, various rules are used to es-timate the fraction of the adult dose (seeinside front cover).Dose interval is important (e.g. anti-infective agents are given at regular in-tervals, 4-, 6- or 8-hourly, to maintainadequate blood levels, while hormonesare given at the same time each day foruniform effect). The time of day must besuitable to the individual’s lifestyle. Forexample, diuretics may be ordered twicedaily and normal convention would seethem administered at a regular interval(e.g. 8–10 hourly during the day); how-ever, for an older person it may be morepracticable to administer the diuretic inthe morning and at lunch time, so thatsleep is not disturbed by frequent mictu-rition, increasing the risk of falls.Drug half-lifeThe half-life of a drug is a function ofboth distribution and elimination. Ingeneral terms, it is the time required forone-half of the amount of drug in thebody to be eliminated. It is of practicaluse in calculating the frequency withwhich multiple doses of a drug can beadministered to keep the blood level be-tween the minimum effective concentra-tion and the threshold for toxicity (e.g.a drug with a very short half-life mayneed to be administered intravenously tomaintain levels, while another drug witha long half-life may be suitable for once-daily administration). Furthermore, adrug with a very long half-life may re-quire patient monitoring for some timeafter the drug has been discontinued.Therapeutic drug monitoringSome drugs have a narrow therapeuticrange (i.e. the difference between over-dosing and underdosing). Serum druglevels are measured to determine thattherapeutic levels are being achievedand/or to prevent toxicity. Informationaccompanying a request form shouldinclude the time the blood sample wastaken, the time the last dose of the drugwas given and its route of administra-tion. The main aim of therapeutic drugmonitoring is to optimise drug therapyby achieving adequate drug levels whileminimising toxicity. It is especially im-portant in those at the extremes of age(i.e. babies and the elderly).Why measure drug levels?Drug levels are measured for a numberof reasons, which include:● to individualise the dose (e.g. lithium,phenytoin, warfarin)● to avoid toxicity (e.g. digoxin, vanco-mycin)● to ensure effective blood levels (e.g.prophylactic antiepileptics, gentami-cin)Sample chapter
    • xixINTRODUCTION● to check adherence to regimen (e.g.antipsychotic agents)● to check that co-morbidities that mayalter drug metabolism and elimina-tion (e.g. renal impairment, hepaticfailure, shock, sepsis) are not affectingblood levels● to ensure that concurrent drug ad-ministration is not affecting bloodlevels● to change the route of administrationor dosage (e.g. from IV or IM to oraladministration) if necessary whilemaintaining adequate serum levels.Drug routeThe effectiveness of a drug often dependson the route of administration. A drugmay have a systemic or local effect de-pending on whether it is taken orally, in-jected or applied topically (see Glossaryfor forms of preparations). Drugs areformulated to meet the requirements forrapid or slow absorption, metabolism orexcretion in order to obtain the requiredtherapeutic blood levels. The two mostcommon routes of drug administrationare oral and parenteral.Oral administrationMany oral preparations are given on anempty stomach because food may de-crease the absorption; however, if gastricirritation is a problem they may be givenwith or immediately after food.It is recommended that a capsule ispreceded by a small amount of waterand then taken with half a glass of wa-ter to prevent it becoming lodged in theoesophagus. A number of medicationsknown to cause oesophageal ulcerationinclude aspirin, bisphosphonates (e.g.alendronate), doxycycline, iron tablets,potassium chloride and zidovudine(Gowan & Roller, 2010). Enteric-coated,slow-release, extended-release, modi-fied-release, sustained-release and con-trolled-dosage tablets should be swal-lowed whole, not crushed or chewed, fora number of reasons, which may include:● absorption will be altered (e.g. MSContin, Keflor CD, Efexor XR, Di-lantin)● medication may become unstable(e.g. Augmentin Duo, Nimotop,Zoton)● they may cause local irritation (e.g.Vibramycin, Fosamax, Cartia, Roac-cutane)● they will not reach the site of the in-tended action (e.g. Creon, Dipentum,Salazoprin)● unacceptable taste (e.g. Neoral, Co-loxyl)● hazardous (e.g. Imuran, Myleran,Leukeran, Cycloblastin).Care must be taken to select the correctformulation of tablets when several dif-ferent formulations and/or dosages exist(e.g. Isoptin (verapamil) is available in 40mg, 80 mg, 120 mg or 160 mg tablets;Isoptin SR is available as 180 mg or 240mg), because the consequences may bevery serious if the wrong formulation isadministered (e.g. substituting Isoptin80 mg (3 tablets), which will act quicklycompared with Isoptin SR 240 mg, whichis a sustained-release preparation andwill act over 24 hours).Parenteral administrationParenteral medications are given eitheras injections or by infusion. The mostcommon routes are intramuscular (IM),subcutaneous (SC) and intravenous (IV).IntramuscularThe three main muscles used for intra-muscular injections are:Sample chapter
    • xxHAVARD’S NURSING GUIDE TO DRUGS● the lateral aspect of the thigh (middlethird when the thigh is divided intothree)● the upper outer quadrant of thedorsogluteal● the deltoid.No more than 5 mL should be admin-istered by intramuscular injection, andless into the deltoid muscle. If a volume> 5 mL is required, the dose should bedivided and given into different sites.Furthermore, the deltoid muscle is notrecommended for intramuscular injec-tion in children.SubcutaneousSubcutaneous injection sites include:● upper outer aspect (middle third) ofthe upper arm● upper anterior thigh● abdomen below the costal marginsto the iliac crests (avoiding the areaaround the navel by about 5 cm).When frequent administration is re-quired (e.g. insulin administration ina patient with diabetes mellitus, dailyheparin injections), administration sitesshould be rotated and documented onthe medication chart to prevent atrophyof the subcutaneous tissue, increasedrisk of infection and pain.IntravenousA drug may be given by direct IV injec-tion as a bolus in a volume of 20 mL orless in under 1 minute, or by slow IVinjection over 5–15 minutes. It is impor-tant to check and adhere to the manu-facturer’s information regarding therequired administration time, becauseadministering some drugs too quicklycan cause pain, damage the blood ves-sel, as well as other adverse effectssuch as flushing, hyper- or hypoten-sion, syncope, arrhythmias, feelings ofwarmth or anxiety, depending on thedrug administered. This method is usedwhen an immediate effect is required orthe drug becomes unstable on recon-stitution or dilution. The intermittentinfusion method is used when a drug isdiluted, when interval dosing is desiredand when slow administration is re-quired. The drug is diluted in 50–250 mLand infused over 15 minutes to 2 hours.This minimises stability and incompat-ibility problems and gives the ‘peak’ and‘trough’ effect in antibiotic therapy. Oneof the advantages of intermittent IVadministration is that the patient canhave an intermittent venous access port,which increases client mobility, comfortand safety, there is a cost benefit fromnot having continuous IV therapy andthe nurse does not have to continuouslymonitor flow rates.When a drug must be highly dilutedand a steady-state blood level is to bemaintained, the continuous infusionmethod is used, in which the drug is di-luted in 500–1000 mL and infused over4–24 hours (e.g. potassium chloride re-quires high dilution and constant bloodlevels to prevent depression of cardiacfunction).The IV flow rate may be controlledby using an infusion pump, a microdripset or a burette. When a drug is addedto the burette during intermittent infu-sion, details of the additive are indicatedon a label that is stuck onto the burette.Any IV drug admixture must be pre-pared aseptically, mixed thoroughly andlabelled with the name and amount ofthe additive, name of person adding theagent, name of person checking the ad-dition and the time of starting the in-fusion. National recommendations foruser-applied labelling of injectable medi-cines, fluids and lines now exist and it isSample chapter
    • xxiINTRODUCTIONimperative that nurses understand andcomply with these as consequences ofnon-labelling can result in a potentiallylife-threatening situation for the patient.These recommendations include colourcoding the route of administration (e.g.red for intra-arterial, blue for intrave-nous, yellow for epidural or intrathecaland beige for subcutaneous), processfor medicine and label preparation (in-cluding label placement), when to dis-card containers of injectable medicinesand special circumstances (ACSQHC,2012b). While these labelling recom-mendations do not apply to enteral,topical or inhalation routes, the generalprinciples still apply as a way of improv-ing practice and decreasing the risk oferrors occurring.An IV admixture should not be ad-ministered if there are signs of physicalincompatibility such as a colour change,loss of clarity or precipitate formation.Chemical and physical compatibilityand stability of admixtures should bechecked before administration. If in anydoubt, consult a pharmacist, textbooks,manufacturer’s information or a druginformation centre.Drugs generally should not be mixedwith blood or blood products.Other methods of administeringmedications include:● transdermal patches, which deliverdrugs through the skin at a steadyconcentration, avoiding first-passmetabolism in the liver and anygastric side-effects. Several types ofdrug, including glyceryl trinitrate,hormones and nicotine, are availableas transdermal patches. Advantagesinclude ease of application and fre-quency of application (once dailyor longer), but the disadvantagesinclude some skin reactions and thelow number of drugs available via thisroute.● intradermal implants, which are sur-gically implanted subcutaneously.Advantages include the frequencyof administration (some may beimplanted for 6–8 weeks or longer);however, they require surgical im-planting and removal.GUIDE FOR SAFE ADMINISTRATIONCheck the order● Check that the information on thedrug name (preferably generic ratherthan trade name), dose, route, fre-quency, time due and when the drugwas last given are all legible (if anydoubt exists, withhold the drug andcheck with the medical officer) andthat the order is signed by the medi-cal officer.● Check that patient details are cor-rect, including any known allergies(it is important to discuss any allergy/sensitivity history with the patient ascross-sensitivity between productsdoes occur).Check the drug● Check the container label against themedication order when selecting thepreparation, before measuring outand when replacing the preparation.● Check the expiry date of the drug.● Check the drug calculation with an-other registered nurse, a pharmacistor medical officer (ask the secondperson to do the calculation inde-pendently, then compare answers,remembering that it is rare to giveless than half a tablet or more than 2tablets or 1 ampoule at a time).Sample chapter
    • xxiiHAVARD’S NURSING GUIDE TO DRUGS● Mix liquid contents thoroughly, butrotate protein preparations gently toprevent denaturation and frothing.● Note any discolouration, precipitateor foreign bodies (and do not admin-ister if they are present).Check the patient● Check the patient’s identity care-fully (check wrist identity band orverbally), taking extra care if thereare patients with the same or similarnames, or if the patient is unknownto the nurse.● Check if the patient has any knownallergies.● Check that the patient knows the rea-son for the medication and discussany query with the medical officerbefore giving it.● Only give medications that you, thenurse, have prepared or seen a phar-macist prepare (i.e. do not adminis-ter an IV drug that was drawn up bysomeone else without you present).● Give the correct drug and dose.● Give to the correct patient.● Give at the correct time.● Give by the prescribed route.● Do not handle tablets.● Wait until oral medications are swal-lowed (never leave medications onbedside tables, lockers or dinnertrays).Documentation● Ensure that the drug administrationsheet is signed after administration.● Document any discrepancies (e.g.patient unable or refuses to takemedication, patient absent, medica-tion not available).● If Schedule 8 drugs are involved,ensure that the drug register is cor-rectly filled in (date, time, patient,drug (form, strength, amount to beadministered), persons administeringdrug, balance of drug remaining, anydrug discarded).● Observe the patient and document inthe patient’s history.● Note beneficial effects and/or reportand chart any adverse effects (seebrief discussion below).● Correctly and safely dispose of equip-ment used (e.g. do not recap syringes– and dispose of them safely in asharps container).● A drug may produce more than oneeffect which may be beneficial or not:— The desired action is the physi-ological response the drug is ex-pected to cause (e.g. antihyperten-sive medications are expected tolower blood pressure)— Side-effects (also called adverseeffects or adverse reactions) aresecondary effects caused by mostdrugs and are generally unde-sirable. Although the terms aresometimes used interchangeably,side-effects tend to be mild innature, whereas adverse reactionsare more serious (e.g. an adverseeffect of acetylsalicylic acid (as-pirin) is increased bleeding time;and a common side-effect of mor-phine is nausea)— Toxic effects develop after pro-longed administration of highdoses of medication, or when adrug accumulates in the bloodbecause of impaired metabolismor excretion. Some drugs such asdigoxin and lithium have a verynarrow safety margin and toxic-ity can occur at recommended ortherapeutic doses— Allergic reactions are unpredict-able responses to a drug thatSample chapter
    • xxiiiSUMMARYacts as an antigen, triggeringthe release of antibodies. Aller-gic reactions may be mild, suchas urticaria (hives) and pruritus(itching), or they may be severe;for example, severe wheezing andrespiratory distress, or life-threat-ening anaphylactic reaction. Somereactions occur within minutes ofthe drug being given, while otherallergic reactions may be delayedfor hours or days (Roach, 2005)— Idiosyncratic reactions are thosewhere the patient’s body eitheroverreacts or underreacts to adrug, or when the reaction is un-usual and there is no known cause(e.g. the antihistamine prometha-zine (Phenergan) is sometimesused for sedation, however, insome people (especially children)it can cause insomnia and agita-tion)— Pharmacogenetic reactions oc-cur because a person may havea genetic trait which leads to ab-normal reactions to drugs (e.g.those with glucose-6-phosphatedehydrogenase (G6PD) deficien-cy may experience haemolysis ifgiven aspirin, chloramphenicolor sulphonamides) (Roach, 2005)— Drug tolerance may also occurwhere a person has a decreasedresponse to a drug over time, ne-cessitating an increase in dosage toachieve the required response (e.g.tolerance to opioids such as mor-phine may occur if given for morethan 10 to 14 days) (Roach, 2005)— Drug interactions occur when onedrugmodifiestheactionofanotherdrug; for example, a drug may ei-ther increase or decrease the actionof other drugs. A drug interactionmay be synergistic (enhances theeffects of another drug) (e.g. pro-benecid may be given orally beforeIM procaine penicillin to increaseand prolong the serum level ofpenicillin), antagonistic (opposesthe effects of another drug) (e.g.protamine sulphate can be givento neutralise the anticoagulant ef-fects of heparin) or additive (wherethe two drug actions are added to-gether (e.g. when alcohol is con-sumed by a person on heparin,the risk of bleeding is significantlyincreased)).SUMMARYAdministering medication is one of thenurse’s most important responsibilitiesand should be treated with the due careit demands. It is not a task merely to becompleted, but rather an opportunity fornurses to increase their own knowledge,to ensure that patients have been edu-cated regarding their medications andto observe patients for both expectedand unexpected responses – part of ho-listic nursing care. The right patient hasa right to receive the right dose of theright medication in the right form at theright time by the right route for the rightduration of therapy. If any doubt exists,the medication should be withheld; re-member, WHEN IN DOUBT, DON’T!!Sample chapter
    • xxivHAVARD’S NURSING GUIDE TO DRUGSAT A GLANCEAVAILABLE FORMSThis section outlines the various formu-lations for the medication.ACTIONBecause this is not a pharmacology text,only a brief description of the action ofeach agent is included. For more detailedinformation, a pharmacology text shouldbe consulted.USEThe most common uses of drugs (includ-ing both hospital and community uses).DOSEDosages listed in this book are thosefor the average adult (unless otherwisestated). Occasionally a paediatric dosemay be included if that particular agentis used predominantly in children (e.g.growth hormone, agents used to treat at-tention deficit disorder).ADVERSE EFFECTSAdverse effects are generally unwanted ef-fects, some of which are predictable andoften dose related. Other adverse effectsmay be unpredictable and occur less fre-quently (e.g. anaphylaxis, anaphylactoidreaction). Very common adverse effectsare considered to be those occurring in10% or more of study participants. Com-mon adverse effects are found in 1–10%,uncommon in 1–0.1% and rare adverseeffects occur in less than 0.1%. The ad-verse effects listed in this book are gen-erally those that are common or verycommon, and rare or less common ad-verse effects are listed when they requiresome action to be taken. For example,thrombocytopenia may be a rare adverseeffect but there is a requirement for regu-lar monitoring of blood counts.INTERACTIONSInteractions occur when one drug altersthe action of the second drug or bothagents affect each other. As with theadverse effects, the interactions listedare those that occur commonly or arethe most dangerous. It should be noted,however, that interactions between anyagents are always possible and cautionshould be taken when multiple agentsare given. For detailed explanations ofhow and why interactions occur, a phar-macological text should be consulted.NURSING POINTS/CAUTIONSThe points in this section are those mostdirectly applicable to nurses and mayinclude:● IV administration rate● monitoring advice● reconstitution and storage recom-mendations● incompatibilitiesPATIENT TEACHING/ADVICEIncluded in this section is important in-formation that the patient should receiveabout his/her medication and includes:● taking with food or fluids● dividing of tablets● grapefruit juice incompatibility● driving warning● when to seek medical advice (see fol-lowing section for detailed patientteaching and advice information)It is assumed that the nurse:● will use an aseptic technique whenreconstituting medicationSample chapter
    • xxvPATIENT TEACHING AND ADVICE● will inspect the solution for any par-ticulate matter or cloudiness● will not use the medication if eitherparticulates or cloudiness is present● will administer the medication usinga safe, aseptic and correct technique● will dispose of sharps in a safe andresponsible manner.These points are not made for every par-enteral agent in the text:● ‘cautions’ are the equivalent of am-ber traffic lights – go slow and takecare. For example, a person with re-nal impairment may not excrete themedication at the same rate as some-one with normal renal function, thusincreasing the risk of adverse effectsand toxicity. Therefore, a reduceddose may be required and/or closemonitoring of renal function anddrug excretion, as well as monitoringfor adverse effects● ‘contraindications’ are the equivalentof red traffic lights – no go!● hypersensitivity to the agent itself isnot listed for every agent as it is as-sumed that this will be checked rou-tinely before administration (i.e. thepatient will be asked ‘Have you hadthis medication before? Did you haveany problems with it?’). Althoughcautions and contraindications areoften more relevant to the personprescribing the medication, it is im-portant that the nurse is also awareof these factors.PATIENT TEACHING AND ADVICEPatient teaching and advice regardingmedications is an essential part of carewhich often involves the nurse, in ad-dition to the pharmacist, doctor and/or other members of a multidisciplinaryteam. If possible, take time to build a rap-port with the patient (and their signifi-cant other/carer/family member, if ap-propriate). It is easier to learn from andask questions of someone with whomyou are comfortable. Also, given theextent of this educational task, it shouldstart on admission rather than a few daysbefore (or on the day of) discharge.There are a number of factors whichmay impact on a person’s ability to learn(Roach, 2005). Examples include:● Environment and available time: Itmay be difficult to teach and/or learnin an area where there are constantdistractions or interruptions. Consid-er using a small room where the doorcan be closed and at a time when thenurse knows that there will not be anyinterruptions (e.g. not during mealbreaks or at other times of reducedstaffing or during visiting hours). Al-though accessing a small room maynot be possible, pulling the curtainaround the person’s bed may alertothers that something is taking placeeven if it doesn’t really afford pri-vacy (curtains are not soundproof).The nurse should also consider howmuch time she/he has available toconduct the session. A short sessioncrammed with too much informationmay cause confusion in the patient,as well as potentially overlooking im-portant information.● Pain and/or Discomfort: Are you ableto concentrate if you are tired, inpain, need to go to the toilet, hungryor thirsty? All of these impact on aSample chapter
    • xxviHAVARD’S NURSING GUIDE TO DRUGSperson’s capacity to concentrate andshould be eliminated or minimisedbefore starting a teaching session● Sensory deficits: Does the patienthave a hearing impairment? Doeshe/she have a hearing aid? Does he/she have it in (and is it turned on)?Can the person read the label on themedication bottle or graduations ona syringe? Is the person dexterousenough to open medication bottlesor operate an injector pen or glucom-eter? Does the person have sufficientcoordination to use an inhaler or is aspacer device required?● Anxiety/stress/fear: These are similarto pain and discomfort and should beminimised or alleviated before start-ing a teaching session● Learning styles: Not everyone learnsin the same manner. Some peoplelearn by reading, others require dem-onstration while others may requireboth (e.g. demonstrate injection orpuffer technique, get the patient topractise, as well as leaving literaturefor them to read). Consider your ownlearning style(s) – how do you preferto learn about a new piece of equip-ment – play with it until you work outhow it works, have it demonstratedto you, read the instruction manualfrom cover to cover or a combina-tion of two or more methods? Weoften teach others in the manner welike to learn, therefore we should alsoconsider teaching using the other,less comfortable, ways. In allow-ing the patient to practise the skills(e.g. injection technique, blood glu-cose monitoring, puffer technique),it gives the nurse an opportunity toobserve and anticipate any problems(e.g. patient may require follow-up bya district nurse on discharge to ensurethe technique is correct)● Literacy: information should be pre-sented at a level which takes intoaccount the patient’s education andreading level● Language and culture: Is an inter-preter required? Does considerationneed to be given of the nature of thematerial (e.g. contraception) and thegenders of the teacher and patient? Itis very difficult to give important in-formation to someone who does notspeak the same language as yourself,or may be able to understand butnot able to ask questions. Further,it is important to use a professionalinterpreter if possible as using fam-ily members (especially children oradults of the opposite sex) can putthem into situations where they arenot comfortable (e.g. teenage soninterpreting for his mother who istaking medication for gynaecologi-cal problems). There is also the issueof privacy and patient confidentialityto consider. It is also necessary to re-member these issues of language andculture if giving the patient writteninformation.Before starting any teaching session, itis important to lay down the ‘groundrules’ (e.g. how long the session will last,what is going to be discussed, follow-up). Factors which can be alleviated orminimised should be attended to beforestarting the session. Other general con-siderations may include:● use of appropriate language. Nurses(and medical professionals in gener-al) often use jargon (e.g. doing ‘obs’ orthe ‘meds’) that can be confusing (anddaunting) for non-medical peopleSample chapter
    • xxviiPATIENT TEACHING AND ADVICE● previous knowledge and skills of theperson. Even if the patient has beenprescribed the medication before,assessing knowledge and any misun-derstandings can be important as thismay improve the patient’s motivationto take the medication, thereby im-proving adherence with the regimen.If the medication is new, it is impor-tant to determine if the informationand/or skill (such as using an inhaleror administration of insulin) requiresmore than one session making dis-charge planning essential. This extratime gives the patient time not onlyto practise skills (supervised and/orunsupervised), but also ask questionsand seek clarification of anything thathe/she has not understand (Roach,2005)● importantly, returning at an agreedtime to review information and fol-low up on any other questions theperson may have.Consideration should be given to includ-ing the following as part of patient teach-ing and advice:● why the person is taking the medi-cation (including the benefits). If theperson has any concerns about tak-ing the medication, he/she should beencouraged to discuss these with his/her doctor before starting● a simplified explanation of how themedication works● importance of telling other healthprofessionals (e.g. dentist, special-ist, surgeon, anaesthetist) that he/she is taking medications (e.g. it maybe necessary to discontinue somemedications before a procedure).This should also include the patientreminding the health professional ofany allergies (including to food(s) orlatex) or other medical conditions(past or present) (such as kidney im-pairment, asthma, tuberculosis, hep-atitis B, heart failure, cancer, blooddisorders, gastric ulcer or bleed-ing, diabetes, high blood pressure),whether he/she smokes or regularlydrinks alcohol● importance of telling doctor if the pa-tient is pregnant, planning to becomepregnant, breastfeeding or planningto breastfeed as many medicationscross the placental barrier and/or areexcreted in breast milk● a recommendation that the patientcarries a list of current medication(with exact names) in wallet/purse sothat he/she can ensure that any otherhealth professional knows what isbeing taken rather than a general de-scription (e.g. ‘small blue pill for myheart’). This may also be important inthe event of an emergency.Dosage● Name and strength of the medication(including information about differ-ing strengths and trade names)● What the medication looks like (e.g.capsules, tablets, liquid, injection)● Dose – this may be straightforward(e.g. patient is ordered 10 mg and tab-lets are supplied as 10 mg) or not (e.g.patient is ordered 15 mg and tabletsare supplied as 10 mg which meanssplitting one tablet. Depending on thedexterity of the person, this may notbe a simple task)● When to take (e.g. morning, evening,same time every day, in relation tofood or other tablets, once per week,once per month)● Not increasing, decreasing or stop-ping medication without seeking ad-vice from doctorSample chapter
    • xxviiiHAVARD’S NURSING GUIDE TO DRUGSHow to take● Swallow whole with glass of water (orother fluids as recommended). Somefluids may interfere with the medi-cation and it is important to knowwhich ones to avoid● Tablets/capsules should generallynot be chewed (unless the tablets arechewable)● Techniques (such as inhalation usinga puffer or injection) will need to bedemonstrated and taught. If patientis unable to manage, considerationshould be given to teaching a carer/family member/significant other, in-volving a community based serviceor discussion with doctor regardingthe appropriateness of the medicationand the risk of non-adherence withthe regimen● What to do if a dose is forgotten oromitted (e.g. seeking advice from apharmacist or doctor; not taking adouble dose to ‘catch up’)● What to do if too much medicationis taken (e.g. contacting doctor, phar-macist or Poisons Information Centre(131 126 in Australia or 0800 764 766in New Zealand), going to the near-est Accident and Emergency Depart-ment)● Length of time that the medicationwill be required (including emphasison completing the course and notstopping the medication abruptly orwithout seeking medical advice)● Whether there is anything that shouldbe avoided while taking the medica-tion (e.g. certain foods or fluids, shak-ing some medications, standing upquickly)Adverse effects● All medications cause some side/ad-verse effects. Some of these may becommon, mild and transient in na-ture, while others are more serious(and may be life threatening). It isimportant for the patient to be madeaware of any potential side/adverseeffects which may require immediatemedical attention. Caution should betaken with explaining side-effects. Itmay be safer and simpler to suggestseeing a doctor if anything unusualoccurs. However, sometimes it isimportant to give specific directionssuch as ‘report to your doctor im-mediately if you develop any yellow-ing of the skin or whites of the eyes,your urine looks darker than usual,you develop nausea, vomiting or ab-dominal pain’● Life threatening side effects (suchas allergic reaction including devel-opment of wheezing, shortness ofbreath, rash, difficulty swallowing)should be emphasised as requiringurgent medical attentionStorage● All medications should be kept out ofreach of children● Medications should be correctlystored. If there are special storagerequirements (such as refrigeration)these should be emphasised (e.g. notusing if left out of the fridge for 12hours or more)● Medications should not be stored in abathroom, near a sink, on a window-sill or in the car as heat and dampnessmay destroy them● Most medications should not befrozen● Medications should be kept in theoriginal containers/packets withlabels intact. Medication should notbe taken if the packaging/container isSample chapter
    • xxixPATIENT TEACHING AND ADVICEtorn or has signs of being tamperedwith● If the medication changes colour,becomes cloudy, foreign particlesare present or develops an odour, themedication should not be used anda pharmacist consulted immediately● Medications have a ‘use by’ (or expi-ry) date and should not be used afterthis date. It is important to show thepatient where this information is lo-cated (it can be difficult to see on somecontainers). Any unused medicationshould be safely disposed of (e.g. re-turned to the pharmacy). Some medi-cations such as eye drops and oint-ments may have a very short life anddeteriorate chemically after this timeOther issues● Following all instructions on pack-age/container (e.g. ‘shake well beforeuse’, ‘keep refrigerated’, ‘take 1 hourbefore meals’)● Seeking advice from doctor if symp-toms do not improve or worsen● Attending doctor’s appointments asrequested, including the need for reg-ular blood or other tests to monitordrug levels (e.g. some medications,such as warfarin, require regularmonitoring of the therapeutic bloodlevel and the dosage may be adjustedaccordingly)● Importance of having a current pre-scription and getting it filled/refilledbefore the medication runs out● Medications should not be given toothers with similar conditions, norkept for the next time the conditionrecurs (e.g. antibiotics used to treatrespiratory infection)● Over-the-counter medications (suchas simple analgesics, antacids, laxa-tives, cold and flu preparations) andherbal preparations or vitamins/minerals may interact with prescribedmedications. It is important to con-sult with doctor or pharmacist beforetaking any of these preparations (in-cluding those bought from the super-market or health food stores)● Consideration should be given towearing a Medic Alert pendant orbracelet or some other form of iden-tification for some conditions/medi-cations (e.g. diabetes, anticoagulants,corticosteroids, insulin) in case of anemergency● Whether the patient is able to man-age the medications alone (e.g. itmay be appropriate to suggest usinga Dosette box or involving a carerin any discussions or referring toa community-based agency (suchas the district nursing service) formonitoring). This may also includethe ability to open containers or splittablets if needed. Most pharmacieswill provide a unit-dose packing ser-vice on request● Warn patient against driving or oper-ating machinery until he/she knowshow the medication will affect them.This is particularly important if themedication has known side effectswhich affect vision, balance, co-ordi-nation or reaction time or increasesthe effects of alcohol. If this is a knownoccurrence, extra labels will be at-tached to containers/packages (e.g.‘this medication may cause drowsinessand may increase the effects of alco-hol. If affected, do not drive a motorvehicle or operate machinery’)● Other medication-specific consid-erations are discussed under patientteaching and advice in each section.Sample chapter
    • xxxHAVARD’S NURSING GUIDE TO DRUGSTECHNICAL REVIEWERSLynne M MacKinnonBPharm, MACPJerry PerkinsBSc, BPharmREVIEWERSKarole HogarthRN, BSc (Hons), PhD (Anatomy)Senior Lecturer, Otago Polytechnic,Dunedin, NZAngela KuciaBN, MA, PhD, Grad Cert EdSenior Lecturer, School of Nursing andMidwifery, University of South Austra-lia, Adelaide; Clinical Practice Consul-tant, Acute Cardiac Assessment, The Ly-ell McEwin Hospital, Adelaide, AustraliaErica O’Donoghue RNBachelor of Nursing, Grad Cert Emer-gency Nursing, Grad Cert in Nursing(Paediatric, Child and Youth HealthNursing), Cert IV Training and Asssess-ment (TAE), MACNLecturer in Acute Care, Bachelor ofNursing, Alfred Clinical School, LaTrobe University, MelbourneNadim RahmanMBBS, AMC (Primary assessment), PGT(General Practice), RN, BN, GCHPEFaculty of Medicine, Nursing and HealthSciences, Monash University, MelbourneSonia ReisenhoferRN, BN, PGDipEN, MCNSchool of Nursing & Midwifery, LaTrobe University, MelbourneSample chapter
    • 1ANALGESICS AND NON-STEROIDALANTI-INFLAMMATORY DRUGS (NSAIDs)Action and use (not paracetamol)During the inflammatory response, ara-chidonic acid is converted by the enzymecyclo-oxygenase (COX) to prostaglan-dins and thromboxane A2, and by theenzyme lipoxygenase to leukotrienes,which produce the pain, swelling, red-ness and heat associated with inflamma-tion (Brenner & Stevens, 2010). Cyclo-oxygenase is present in two forms thathave distinct properties. Cyclo-oxygen-ase-1 (COX-1) is found in the stomach,intestines, kidneys and platelets, andappears to be responsible for functionsinvolving prostaglandins, such as renalfunction, platelet aggregation and cy-toprotection of the stomach. NSAIDsinhibit COX-1 non-selectively, resultingin the common side-effects of gastriculceration and, to a lesser extent, renaltoxicity and increased risk of bleeding.Cyclo-oxygenase-2 (COX-2) is foundin fewer tissues (including the brain,renal glomeruli and vasculature) at lowlevels; however, during inflammation,pro-inflammatory substances lead to anincrease in COX-2 levels (Brenner & Ste-vens, 2010). Selectively inhibiting COX-2decreases the signs and symptoms of in-flammation and pain with less likelihoodof causing gastric or renal problems.Recently, cyclo-oxygenase-3 (COX-3)has been discovered. It is thought thatparacetamol inhibits COX-3. possiblyexplaining its lack of anti-inflammatoryaction (Brenner & Stevens, 2010).The NSAIDs are a heterogeneousgroup of compounds, often chemicallyunrelated, that share some therapeuticactions and side-effects because of theirnon-selective inhibition of cyclo-oxygen-ase. Not all drugs in this class possess theanti-inflammatory, antipyretic and anal-gesic characteristics to the same degree(Brenner & Stevens, 2010). When usedas analgesics, these drugs are usually ef-fective against low to moderate intensitypain only. As anti-inflammatory agents,they are used in treating musculoskeletaldisorders, providing symptomatic relieffrom pain and inflammation, but leav-ing the progression of the disease courseunchanged. As antipyretics, they arethought to inhibit hypothalamic pros-taglandins that act on the thermoregu-latory centre in the hypothalamus. TheANALGESICS, NON-STEROIDALANTI-INFLAMMATORY DRUGS(NSAIDS) AND DISEASE-MODIFYINGANTIRHEUMATIC DRUGS (DMARDS)Sample chapter
    • 2HAVARD’S NURSING GUIDE TO DRUGSCOX-2 inhibitors are a newer class ofagents with similar properties to those ofother NSAIDs without having the sameside-effects (especially gastrointestinal),because of their selective inhibition.Most NSAIDs are taken orally, whilesome are applied topically to relievemuscular and/or rheumatic pain, andothers are used in ophthalmic prepara-tions to reduce ocular inflammation.Adverse effects (not paracetamol)● epigastric pain, nausea, vomiting,diarrhoea, abdominal pain/cramps,heartburn, dyspepsia, flatulence,bloating, anorexia, constipation● gastrointestinal bleeding and/orulceration● rash, pruritus● tinnitus, temporary deafness● headache, dizziness, vertigo, fatigue,drowsiness● prolonged bleeding time● fluid retention, oedema● hypertension (new, or worsening ofexisting)● increased risk of cardiovascularthrombotic events (COX-2 inhibitors)● elevated liver enzymes (ALT, AST),jaundice, hepatitis● blood dyscrasias, iron-deficiencyanaemia● may mask signs and symptoms ofinfection● (prolonged therapy, high dose) visualdisturbances, acute interstitial ne-phritis with haematuria, proteinuria,nephrotic syndrome, renal papillarynecrosis, liver toxicity● hypersensitivity reactions (especiallyinthosewithasthmaorfamilyhistory)● (rare) anaphylactoid reactions, angio-edemaInteractions (not paracetamol)● may increase blood lithium or digox-in levels (except ketoprofen), therebyincreasing the risk of toxicity; lithiumor digoxin levels should be closelymonitored, especially when startingor stopping therapy with NSAIDs● use with aspirin or other NSAIDsis not recommended because of in-creased risk of gastrointestinal side-effects● use caution and close monitoring ifwarfarin is given with NSAIDs be-cause of increased risk of haemor-rhage● increased risk of nephrotoxicity ifcyclosporin or tacrolimus are givenwith NSAIDs● methotrexate toxicity may occur ifNSAIDs are given within 24 hours ofmethotrexate therapy● use of quinolone antibiotics andNSAIDs may lead to convulsions (notcelecoxib)● risk of gastric ulceration is increasedif aspirin or NSAIDs are taken withalcohol and/or corticosteroids● increased risk of bleeding if givenwith SSRIs, zidovudine or antiplate-let agents● use of antacids may reduce absorp-tion of aspirin or NSAIDs (exceptketoprofen, ketorolac trometamol,sulindac and piroxicam)● may decrease excretion of aminogly-coside antibiotics, increasing risk oftoxicity● avoid use with other nephrotoxicagents● plasma levels may be increased ifgiven with probenecid● may increase serum potassium lev-els if given with potassium-sparingdiureticsSample chapter
    • 3ANALGESICS, NSAIDs AND DMADs● may decrease diuretic, natriureticand antihypertensive effects of loop,potassium-sparing and thiazide di-uretics by inhibiting the synthesis ofrenal prostaglandin● may potentiate effects of sulfonyl-ureas● may reduce antihypertensive effectsof beta-adrenergic blocking agents,ACE inhibitors and angiotensin IIantagonists● risk of renal impairment is increasedif NSAIDs, thiazide diuretics andACE inhibitors/angiotensin II antag-onists are given together, especially inthe elderly or those with pre-existingrenal impairment● increased risk of bleeding if givenwith Ginkgo bilobaNursing points/Cautions(not paracetamol)● before starting therapy, the patientshould be assessed for any allergicreactions after prior aspirin or otherNSAID therapy, as cross-sensitivityoccurs● any history of asthma (may induceasthma attack in susceptible individ-uals) or gastric ulceration/bleeding(due to increased risk of both) shouldbe assessed before starting therapy● if administered preoperatively, pa-tient should be carefully monitoredfor any signs of bleeding intra- orpostoperatively● regular ophthalmological examina-tion, haematological and liver en-zyme monitoring should all be per-formed during prolonged therapy● in patients with concurrent hyper-tension and managed with antihy-pertensive agents (beta-adrenergicblocking agents, ACE inhibitors andangiotensin II antagonists) regularmeasurement of BP is recommendedbefore starting therapy and then atregular intervals● caution if used in those with hyper-tension, congestive cardiac failure orpre-existing oedema because of in-creased potential for fluid retentionand oedema● caution if given to those with pre-existing renal disease, uraemia orbleeding disorders● caution if used in those with in-flammatory bowel disease (IBD) asNSAIDs have been associated withexacerbation of IBD-associated spon-dyloarthropathies● contraindicated in those with a his-tory of peptic or gastrointestinalulceration or bleeding● contraindicated in those with salicy-late hypersensitivity or with ‘aspi-rin triad’ (person with asthma whoexperiences rhinitis with/withoutnasal polyps, or experiences severebronchospasm after taking aspirin orNSAIDs)Patient teaching and advicefor NSAIDs● recommend taking NSAIDs withfood or milk (e.g. after meals) to re-duce gastric irritation● patients should be warned to imme-diately report to their doctor any:– changes in hearing or visual dis-turbances– nausea, tiredness, lethargy, itch-ing, yellowing of skin, eyes andurine, flu-like symptoms or ab-dominal tenderness (in upperouter right quadrant, as these aresigns of impending liver toxicity)Sample chapter
    • 4HAVARD’S NURSING GUIDE TO DRUGS● patient should be advised to imme-diately seek medical attention if skinrash, hives, blistering or peeling skin,mouth ulcers or swelling of face, lips,mouth, tongue or throat, or wheez-ing/difficulty breathing occurs● caution patients not to drive or oper-ate machinery if dizziness, drowsi-ness or visual disturbances occur● (gel) instruct patient to only applygel to intact skin, avoiding any areasof broken or infected skin and washhands after applying gel and avoidcontact with eyes or mouth● counsel female patients not to takeNSAIDs during pregnancy, especial-ly during third trimester. If the pa-tient becomes pregnant, she shouldbe advised to tell doctor immediatelyuse of these agents during the latterstages of pregnancy may cause closureof the fetal ductus arteriosus, fetal renalimpairment, inhibition of platelet aggre-gation and may delay labour and birth.Therefore, continuous treatment withthese agents during the third trimesterof pregnancy should only be undertakenif the benefits are thought to greatly out-weigh the disadvantagesnot recommended during labour ordeliverycaution should also be used duringbreastfeeding because some NSAIDsand/or their metabolites are excretedin breast milk and their actions on thenewborn may be unknownASPIRIN (Aspro preparations, AsproClear Extra Strength, Astrix 100, AstrixTablets, Cardiprin 100, Cartia, Disprinpreparations, Solprin)Available formsCapsules: 100 mg; Tablets: 100 mg, 300mg, 320 mg, 500 mg; Tablets (entericcoated): 100 mg, Tablets (effervescent):300 mg, 500 mgAction● see general Action for NSAIDs (p. 1)● antiplatelet (see Antiplatelet Agents)● aspirin is converted to salicylatemainly in the GI tract● absorption is dependent on formula-tion (e.g. soluble formulation increas-es rate of absorption)● half-life of aspirin is about 30 minutes,half-life of salicylate is dose depen-dentUse● relief of mild to moderate non-visceralpain● headache, migraine● acute febrile illnesses (not for childrenor teenagers)● dysmenorrhoea● rheumatic pain, including juvenilerheumatoid arthritis● antiplatelet therapy (only on medicaladvice)● cold and flu symptoms● toothacheDose● (analgesic, antipyretic) 300–1000 mgorally with food 4–6 hourly as required(up to 4 g/day) OR● (effervescent tablets) 300–1000 mgorally dissolved in ½ glass of water4-hourly as required (up to 4 g/day) OR● (antiplatelet) 100 mg dailyAdverse effects● see general Adverse effects forNSAIDs (p. 2)Interactions● see general Interactions for NSAIDs● may increase blood levels of sodiumvalproate, phenytoin, sulfonamidesand methotrexate increasing risk oftoxicity and/or adverse effects● aspirin absorption is increased bymetoclopramide during migraineattackSample chapter
    • 5ANALGESICS, NSAIDs AND DMADs● action of probenecid may be reducedif given with aspirin● hypoglycaemic action of sulfonyl-ureas may be increased if given withhigh-dose aspirin and therefore bloodglucose levels should be closely mon-itored● excretion is increased if given withurinary alkalinisers● may antagonise diuretic action ofspironolactone● rate and extent of absorption isincreased by caffeine● hydrocortisone may increase clear-ance. Further, when hydrocortisoneis ceased, blood levels of aspirin mayrise significantly, increasing risk of ad-verse effects and/or toxicity● may interfere with a number of labo-ratory tests, including measurementof heparin activity, urinary glucoseoxidase test in the presence of gly-cosuria, fluorometric assay of 5-hy-droxyindole acetic acid, serum uricacid and phenylketonuriaNursing points/Cautions● see general points for NSAIDs● soluble, effervescent, buffered andenteric-coated salicylate preparationsreduce gastric irritation● enteric-coated and sustained-actionpreparations have delayed absorp-tion, which is useful for regular long-term therapy● elderly patients are at greater risk ofadverse effects, including tinnitus,nausea, anorexia and gastric irritation● tinnitus (with normal hearing) is areliable index of therapeutic plasmalevel, but may not be detected in pa-tients with hearing loss● symptoms of salicylism (chronic sa-licylate intoxication) are dizziness,tinnitus, deafness, sweating, nausea,vomiting, headache and mental con-fusion● symptoms of acute salicylate poi-soning include hyperventilation anddisturbed acid–base balance. Othersymptoms include fever, dehydra-tion, gastrointestinal symptoms,hypoglycaemia, bleeding and en-cephalopathy. In severe poisoning,CNS symptoms such as delirium,tremor, hallucinations, restlessnessand coma are common. Treatmentinvolves determining salicylate lev-els, stomach emptying with/withoutforced alkaline diuresis (dependingon blood salicylate level), treatmentof hyperthermia and dehydrationand correction of any disturbance inacid–base balance, as well as main-tenance of renal function. If conditionworsens, haemodialysis, peritonealdialysis or exchange transfusion maybe necessary● aspirin should be avoided in infants,children and adolescents, including forthe treatment of fever and/or musclepain associated with febrile, viral ill-ness because of the association withReye’s syndrome (see Glossary)Patient teaching and advice● see general Patient teaching andadvice (p. xxiii) and general Patientteaching and advice for NSAIDs● stopping aspirin for any reason (e.g.donation of blood) should be dis-cussed with doctor before discon-tinuing therapy● effervescent and soluble preparationsshould be dissolved in ½–1 glass ofwater for more rapid absorption● warn patients that sustained-releaseand enteric-coated preparationsshould be swallowed whole and notcrushed or broken● advise patient to avoid aspirin within30 minutes of alcohol● instruct patient to stop aspirin a weekbefore any surgical procedure as therisk of bleeding is increased● blood donors should not take aspirinin the week preceding the donationSample chapter
    • 6HAVARD’S NURSING GUIDE TO DRUGS● if patient is on a low sodium diet, he/she should be cautioned that effer-vescent preparations contain sodiumNote● contained in Alka-Seltzer, AsasantinSR, Aspalgin, Clopidogrel WinthropPlus Aspirin, Codis, CoPlavix, DisprinForte, DuoCoverBENZYDAMINE (Difflam Solution, Anti-inflammatory Throat Spray and Gel)Available formsThroat spray: 1.5 mg/mL; Gel: 3%, 5%;Solution: 22.5 mg/15 mLAction● analgesic, anti-inflammatoryUse● relief of inflammatory conditions ofthe mouth and throat (e.g. tonsillitis,radiation mucositis) (see Eye, ear,nose and throat agents)● (topically) rheumatic disordersDose● (rheumatic disorders) 3% or 5% gelmassaged into affected area 3–6times daily (maximum 6 times daily insevere conditions) for up to 14 daysAdverse effects● (topical application) erythema, rash,photosensitivityPatient teaching and advice● patients should be advised to washhands after applying gel and avoidcontact with eyes or mouth● see general Patient teaching andadvice (p. xxiii)Note● contained in Difflam preparations(Lozenges, Mouth Gel and Solution),Logicin Rapid Relief LozengesBUFEXAMAC (Paraderm Cream)Available formCream: 50 mg/gAction/Use/Dose/Adverse effects/Nursing points/Cautions● topical anti-inflammatory (see Derma-tological agents)Note● contained in Paraderm Plus, ResolveBalmCELECOXIB (Celebrex)Available formsCapsules: 100 mg, 200 mgAction● COX-2 inhibitor preventing prosta-glandin synthesis with actions similarto other NSAIDs● half-life 4–15 hoursUse● osteoarthritis, rheumatoid arthritis,ankylosing spondylitis● primary dysmenorrhoea● (short-term) pain management post-surgery or musculoskeletal/soft tissueinjuryDose● (osteoarthritis, ankylosing spondylitis)200 mg orally daily as single dose or2 divided doses OR● (rheumatoid arthritis) 200 mg orallydaily in 2 divided doses, increasingto 400 mg daily for short-term man-agement of disease flares/exacerba-tions OR● (primary dysmenorrhoea) 400 mgorally daily as single dose or 2 divideddoses (first day), then 200 mg dailyon following days for up to 5 daysmaximum OR● (acute postsurgical pain, musculo-skeletal and/or soft tissue injury) ini-tially 400 mg orally daily, then 200 mg1–2 times daily on following days forup to 5 days maximumSample chapter
    • 7ANALGESICS, NSAIDs AND DMADsAdverse effects● see general Adverse effects forNSAIDs, however, gastrointestinaladverse effects occur less frequently● increased risk of cardiac and throm-botic eventsInteractions● increased plasma levels may occur ifgiven with fluconazole● increased risk of renal impairment ifgiven with ACE inhibitor/angiotensinreceptor antagonist and thiazide di-uretic at same time● may decrease antihypertensive ef-fects of ACE inhibitor or angiotensinreceptor antagonist● may decrease natriuretic effect offrusemide and thiazide diuretics be-cause of renal prostaglandin synthe-sis inhibition● increased risk of gastrointestinal ad-verse effects if given with oral gluco-corticoids, especially in the elderly● increased risk of gastrointestinal ad-verse effects if given with aspirin● may increase plasma levels of lithi-um and warfarin, thereby increasingrisk of toxicity; lithium and warfarinlevels should be closely monitored,especially when starting, stopping oraltering doses of celecoxib● decreased plasma levels may occur ifgiven with aluminium- or magnesium-containing antacids● not recommended with other NSAIDsNursing points/Cautions● any dehydration should be correctedbefore starting therapy● any skin reactions usually occur with-in 4 weeks of starting therapy● to lessen the risk of cardiovascularevents, the lowest effective doseshould be used for the shortest pos-sible duration● (long-term treatment) haemoglobin orhaematocrit levels should be moni-tored regularly for signs of anaemia● contraindicated in those with sensitiv-ity to sulfonamides● contraindicated in the treatment ofpain in those undergoing coronaryartery bypass graft (CABG) surgery● contraindicated in those with unsta-ble or significant ischaemic heart dis-ease, peripheral arterial disease and/or cerebrovascular disease; conges-tive heart failure; severe liver or kidneyimpairment or creatinine clearance< 30 mL/min● see general Nursing points/Cautionsfor NSAIDs (p. 3)Patient teaching and advice● advise patient to take antacids 2hours before or after celecoxib● warn patient to seek medical adviceimmediately if fainting, collapse,shortness of breath, chest pain or ir-regular heart beat occurs● see general Patient teaching andadvice (p. xxiii) and general Patientteaching and advice for NSAIDs (p. 3)CHOLINE SALICYLATE (Bonjela MouthUlcer Gel, Bonjela Teething Gel, HerronBaby Teething Gel)Available formGel: 15 gAction● local analgesicUse● painful oral irritation (e.g. teething)● lesions of the mouthDose● (adult) massage 1 cm gel to painfularea 3-hourly OR● (infant > 4 months) massage 0.5 cmgel to painful area 3-hourly if required(up to 6 applications/24 hours)Adverse effects● transient stinging on applicationSample chapter
    • 8HAVARD’S NURSING GUIDE TO DRUGSNursing points/Cautions● contraindicated in babies less than4 months old or children under 12 incombination with aspirin-containingproducts (to avoid excessive salicy-late levels)Patient teaching and advice● gel should not be applied directly todenturesNote● contained in Curash Family Oral PainRelieving Gel, Ora-Sed Jel, Seda-GelDICLOFENAC SODIUM (Clonac,Dencorub Anti-Inflammatory Gel,Dinac, Fenac, Imflac, Solaraze 3% Gel,Viclofen, Voltaren, Voltaren Ophtha)DICLOFENAC POTASSIUM (VoltarenRapid, Voltfast)DICLOFENAC DIETHYLAMMONIUM(Voltaren Emulgel)Available formsGel: 1%, 3%; Tablets (enteric coated):25 mg, 50 mg; Tablets (rapid release):12.5 mg, 25 mg, 50 mg; Suppositories:12.5 mg, 25 mg, 50 mg, 100 mg; Powder:50 mg/sachet; Eye Drops: 1 mg/mLAction● see general Actions for NSAIDsUse● rheumatoid arthritis, osteoarthritis● acute or chronic inflammatory condi-tions● primary dysmenorrhoea● acute migraine, headache● cold and flu symptoms● dental pain, back ache, muscle pain● postoperative pain management inchildren● postoperative inflammation followingeye surgery (see Eye, ear, nose andthroat agents)Dose● (primary dysmenorrhoea) initially50–100 mg orally daily, starting withonset of symptoms, increasing gradu-ally if necessary (daily maximum 200mg) OR● (arthritis, inflammatory conditions) ini-tially 75–150 mg orally daily in 2–3 di-vided doses, reducing to 75–100 mgorally in divided doses for long-termtherapy (enteric-coated tablets, rapidrelease tablets) OR● (arthritis, inflammatory conditions)initially 25 mg orally, followed by12.5–25 mg orally 4–6 hourly if need-ed (daily maximum 75 mg) (12.5 mgrapid release tablets) OR● (acute migraine) 50 mg orally at firstsign of migraine, followed by 50 mg2 hours later if pain is not relieved. Ifneeded, further 50 mg can be takenat 4–6 hourly intervals (daily maximum200 mg) OR● (postoperative pain management inchildren aged 12 months and above)initially 1–2 mg/kg, followed by 1 mg/kg 3 times daily for up to 3 days ifneeded (daily maximum 3 mg/kg)(suppositories) OR● (local pain, soft tissue injury, soft tis-sue rheumatism) apply gel to affectedarea and rub gently 3–4 times daily forup to 14 daysAdverse effects/Interactions● see general Adverse effects and Inter-actions for NSAIDs● may impair female fertility● (suppositories) worsening of haemor-rhoids● (gel, occasionally) itching, reddenedor scaly skin, photosensitivityNursing points/Cautions● care should be taken when selectingtablets as rapid release and slow-release forms are available● 100 mg suppositories should not beused for children or teenagersSample chapter
    • 9ANALGESICS, NSAIDs AND DMADs● suppositories should not be used ininfants under 12 months● suppositories are contraindicated inproctitis● tablets contain lactose and are there-fore not recommended in galactoseintolerance, severe lactase deficiencyor glucose/galactose malabsorption● see general points for NSAIDsPatient teaching and advice● instruct patient that tablets should beswallowed whole with fluids, prefer-ably before food for better absorptionand efficacy, but can be taken withfood if stomach is upset● advise patient that diclofenac shouldnot be used to prevent migraine (pro-phylaxis), only for the managementand should be taken at first sign ofheadache● patients who experience night painand/or morning stiffness should beadvised to take oral treatment duringthe day and suppositories at bedtimefor better control of symptoms (dailymaximum 150 mg)● patient should be instructed thatpowder should be dissolved in non-carbonated water and may be drunkeven if solution appears cloudy● instruct adult patient in correct tech-nique for suppository insertion, in-cluding the need to empty bowelbefore insertion● patients with lactose or galactoseintolerance should be warned thattablets contain lactose● see general Patient teaching andadvice (p. xxiii) and general Patientteaching and advice for NSAIDsNote● contained in Anthrotec 50 with Miso-prostolETORICOXIB (Arcoxia)Available formsTablets: 30 mg, 60 mg, 120 mgAction● COX-2 inhibitor preventing prosta-glandin synthesis with actions similarto other NSAIDsUse● osteoarthritis● acute gouty arthritis● primary dysmenorrhoea● minor dental painDose● (osteoarthritis) initially 30 mg orallydaily, increasing to 60 mg orally dailyif needed OR● (acute gouty arthritis, primary dys-menorrhoea, dental pain) 120 mgorally daily (maximum 8 days)Adverse effects● dizziness, headache, diarrhoea● dyspepsia, upper abdominal pain,diarrhoea● dyspnoea● peripheral oedema● hypertension● increased risk of myocardial infarctionand stroke● (rare) jaundiceInteractions● may increase levels of ethinyloes-tradiol resulting in an increased riskof adverse effects such as venousthromboembolic events in at-riskwomen● may decrease antihypertensive ef-fects of ACE inhibitor or angiotensinreceptor antagonist● may decrease natriuretic effect offrusemide and thiazide diuretics be-cause of renal prostaglandin synthe-sis inhibition● not recommended with aspirin orother NSAIDs● increased risk of gastrointestinal ad-verse effects if given with aspirin● may reduce clearance of lithium, in-creasing plasma levels and risk oftoxicitySample chapter
    • 10HAVARD’S NURSING GUIDE TO DRUGS● decreased levels (and therefore de-creased analgesic effect) may occurif given with rifampicinNursing points/Cautions● any dehydration should be correctedbefore starting therapy● hypertension should be controlledbefore starting therapy. BP should bemonitored every 2 weeks throughouttherapy and stopped if there is a sig-nificant increase● to lessen the risk of cardiovascularevents, the lowest effective doseshould be used for the shortest pos-sible duration● caution if used in those with in-creased risk factors for cerebrovas-cular events (diabetes, hypertension,hypercholesterolaemia, family historyof ischaemic heart disease, cardiacfailure and/or smokers)● contraindicated in those who haverecently undergone CABG surgery orangioplasty● contraindicated in those with un-stable or significant ischaemic heartdisease, peripheral arterial diseaseand/or cerebrovascular disease; hy-pertension which is not adequatelycontrolled, congestive heart failure;severe liver or kidney impairment orcreatinine clearance < 30 mL/min, ac-tive peptic ulceration or GI bleeding● see general Nursing points/Cautionsfor NSAIDsPatient teaching and advice● warn patient to seek medical adviceimmediately if any of the followingoccurs:– fainting, collapse, shortness ofbreath, chest pain or irregularheart beat– vomiting blood or material thatlooks like coffee grounds, bloodydiarrhoea, black sticky bowel mo-tions or bleeding from the backpassage● advise patient against driving oroperating machinery if dizziness oc-curs● see Patient teaching and advice forNSAIDs or general Patient teachingand advice (p. xxiii)FLURBIPROFEN (Strepfen Intensive)FLURBIPROFEN SODIUM (Ocufen EyeDrops)Available formsEye drops: 300 microgram/mL (0.03%);Lozenges: 8.75 mgAction● analgesic, anti-inflammatory andantipyretic agent that blocks theprostaglandins that constrict the irissphincter independently of the cho-linergic systemUse● intra-operative miosis (see Eye sec-tion of Eye, ear, nose and throatagents)● severe sore throat (see Oropharynxsection of Eye, ear, nose and throatagents)IBUPROFEN (Advil, Brufen, Bugesic,Bugesic Oral Suspension, DimetappChildren’s Pain and Fever ReliefIbuprofen Suspension, DimetappInfant’s Pain and Fever Relief IbuprofenColour Free Suspension, iProfenSuspension for Children, Nurofen,Nurofen for Children, Nurofen forChildren Infant Drops, Nurofen Gel,Nurofen Liquid Capsules, NurofenMeltlets Lemon, Nurofen TensionHeadache, Panafen IB, ProVen, Rafen,Tri-Profen)Sample chapter
    • 11ANALGESICS, NSAIDs AND DMADsIBUPROFEN LYSINE (Nurofen MigrainePain)Available formsCapsules: 200 mg; Tablets: 200 mg, 400mg; Tablets (melt in mouth): 200 mg;Syrup/Suspension: 100 mg/5 mL, 200mg/5 mL; Gel: 5%Action● see general Action for NSAIDs● half-life approximately 2 hoursUse● rheumatoid arthritis, including juvenilerheumatoid arthritis, osteoarthritis● primary dysmenorrhoea● migraine (see Antimigraine agents)● acute/chronic pain with inflammatorycomponentDose● (rheumatoid arthritis, osteoarthritis(acute exacerbation)) initially 1200–2400 mg orally daily in 3–4 divideddoses with food, reducing to 1600 mgwhen symptoms stabilise OR● (primary dysmenorrhoea) 400–800mg orally with food at the first sign ofpain or menstrual bleeding, then 400mg 4–6 hourly up to a maximum dailydose of 1600 mg OR● (minor aches and pains, dental pain,headache) 200–400 mg orally 4–6hourly as needed, up to a daily maxi-mum of 1600 mg OR● (topical) apply 4–10 cm of gel 4-hourly(as needed) to affected area and rubgently (maximum 4 applications daily)Adverse effects/Interactions/Nursingpoints/Cautions/Patient teachingand advice● see general points for NSAIDs● see general Patient teaching andadvice (p. xxiii)● oral solution should be shaken wellbefore use● meltlet tablets should be placed ontongue, allowed to dissolve and thenswallowed or may be taken with waterNote● contained in Nurofen Cold and Flu,Nurofen Plus, Panafen Plus, ProVenPlus, Sudafed Sinus+ Anti-Inflamma-tory Pain Relief CapletsINDOMETHACIN (Arthrexin, Indocid,Indocid PDA)Available formsCapsules: 25 mg; Vial: 1 mg; Supposito-ries: 100 mgAction● see general Action for NSAIDs● half-life is about 4.5 hoursUse● rheumatoid arthritis, osteoarthritis,ankylosing spondylitis● degenerative hip disease● gout● bursitis, capsulitis, tenosynovitis● sprains and strains● low back pain (lumbago)● inflammation, pain and oedema fol-lowing orthopaedic surgery or reduc-tion and immobilisation of fracturesand dislocations● primary dysmenorrhoea● medical closure of patent ductus ar-teriosus in newborn infantsDose● 50–200 mg orally daily with food individed doses (daily maximum 200mg) OR● 100 mg rectal suppository once ortwice daily if oral therapy not toler-ated OR● in combination e.g. 25 mg orally 2–4times daily and 100 mg rectal sup-pository at night (to a total of 200 mg)OR● (acute gouty arthritis) 150–200 mgorally daily with food in divided dosesuntil symptoms subside OR● (primary dysmenorrhoea) 25 mg orally3 times daily with food at the first signof pain or menstrual bleeding andSample chapter
    • 12HAVARD’S NURSING GUIDE TO DRUGScontinuing for as long as the symp-toms usually last OR● (closure of patent ductus arteriosusin newborn) course of 3 IV doses at12–24 hour intervals with dosagedependent on age of infant: initially0.2 mg/kg, then 0.1–0.25 mg/kg forremaining 2 dosesAdverse effects● see general Adverse effects forNSAIDs (p. 2)● may aggravate pre-existing psychiat-ric disturbances, epilepsy or parkin-sonism● (IV, newborns) transient decreasedurine output, elevated blood urea andcreatinine, reduced creatinine clear-ance, intracranial bleeding, tissueirritation at IV site● (suppository) burning, pain, discom-fort, itching, proctitis, tenesmusInteractions● see general Interactions for NSAIDsNursing points/Cautions● see general points for NSAIDs● (rheumatic conditions) loading dosenot required● avoid extravasation as solution isirritating to tissue● IV indomethacin should only be ad-ministered in specialised units withneonatologist supervision● IV solution should be prepared witheither 0.9% sodium chloride or waterfor injection (preservative free). Thepreservative benzyl alcohol maycause toxicity in newborns andshould be avoided● further dilution of IV solution is notrecommended as there is a risk ofprecipitation occurring● IV dose should be given over 5–10seconds● urine output of newborn must beclosely monitored and IV indo-methacin not administered if outputis less than 0.6 mL/kg/hour. Serumelectrolytes and renal function shouldbe closely monitored during therapy● infant should be closely monitored forany signs of bleeding● if ductus closes after first dose andremains closed for 48 hours, no fur-ther doses are required● second course of IV indomethacin (1–3doses) may be given to newborn at12–24 hour intervals if ductus reopens.Surgery may be necessary if newbornremains unresponsive after 2 courses(6 doses total) of IV indomethacin● IV indomethacin is contraindicatedin infants with untreated infections,bleeding or coagulation disorders,necrotising enterocolitis, impaired re-nal function, congenital heart diseasewhere pulmonary or systemic bloodflow is dependent on patency of duc-tus arteriosus● (suppository) contraindicated in thosewith proctitis or recent rectal bleeding● (IV) contraindicated if infection ispresent or active intracranial/gastro-intestinal bleeding is presentPatient teaching and advice● see general points for NSAIDs● see general Patient teaching and ad-vice (p. xxiii)● patients who experience night painand/or morning stiffness should beadvised to take oral treatment duringthe day and suppositories at bedtimefor better control of symptomsKETOROLAC TROMETAMOL (Acular EyeDrops, Ketoral Injection, Toradol)Available formsTablets: 10 mg; Ampoule: 10 mg/mL,30 mg/mL; Eye drops: 5 mg/mLAction● inhibits prostaglandin synthesis byinhibiting COX● potent peripherally-acting analgesic● half-life 5–6 hoursSample chapter
    • 13ANALGESICS, NSAIDs AND DMADs● platelet inhibition reverses 24–48hours after stoppingUse● pain after surgery (short term not ex-ceeding 5 days)● seasonal allergic conjunctivitis (shortterm); prophylaxis and reduction ofinflammation after cataract surgery(see Eye section of Eye, ear, nose andthroat agents)Dose● (under 65 years) initially 10–30 mgIM, followed by 10–30 mg 4–6 hourly(maximum 90 mg daily) OR● (over 65 years, less than 50 kg or lesssevere pain) initially 10–15 mg IM, fol-lowed by 10–15 mg 4–6 hourly (maxi-mum 60 mg daily) OR● (under 65 years) 10 mg orally 4–6hourly (maximum 40 mg daily) OR● (over 65 years) 10 mg orally 6–8 hour-ly (maximum 30–40 mg daily)Adverse effects● (injection site) pain, tingling, ecchy-mosis, bruising● may impair female fertility● (rare, but fatal) haemorrhage● see general Adverse effects for NSAIDsInteractions● increased risk of seizure activity ifgiven with antiepileptic agents (e.g.phenytoin, carbamazepine)● may be used with opioid analgesicsto achieve optimal analgesia or whenthe sedative or anxiolytic effect of theopioid is wanted● increased risk of hallucinations if giv-en with fluoxetine or alprazolam● contraindicated with aspirin, NSAIDs,pentoxifylline (oxpentifylline), lithiumor probenecid● see general interactions for NSAIDsNursing points/Cautions● any hypovolaemia should be correct-ed before administration of ketorolactrometamol● IM injection should be given deeplyand slowly into large muscle● pressure should be applied to injec-tion site for 15–30 seconds to de-crease local effects● total duration of use should not ex-ceed 5 days because the risk ofadverse effects increases with pro-longed use● conversion from parenteral to oralroute should occur as soon as prac-ticable● contraindicated via epidural or intra-thecal route● contraindicated in those with dehy-dration, hypovolaemia, moderate/severe kidney impairment, coagula-tion disorders or on anticoagulanttherapy, surgical procedures with highrisk of bleeding, history of bleeding(gastrointestinal or intracranial)● not recommended for obstetric pro-cedures● see general points for NSAIDsKETOPROFEN (Orudis Gel, Orudis SR,Oruvail SR)Available formsCapsules (sustained release): 100 mg,200 mg; Suppositories: 100 mg; Gel:2.5%Action● see general actions for NSAIDs● half-life less than 2 hoursUse● rheumatoid arthritis, osteoarthritis● musculoskeletal inflammation or in-juryDose● 100 mg rectal suppository at nightsupplemented as required with 100mg orally 1–2 times daily OR● 100–200 mg orally daily with food OR● massage sufficient gel into affectedarea 2–4 times daily for up to 7 daysSample chapter
    • 14HAVARD’S NURSING GUIDE TO DRUGSAdverse effects● see general Adverse effects forNSAIDs (p. 2)● non-bacterial cystitis (bladder pain,dysuria, haematuria, increased mic-turition and frequency)● (suppositories) pain, burning, itching,tenesmus● (gel) allergic skin reactions, localisederythema (especially if skin is ex-posed to UV rays during therapy)Interactions● see general Interactions for NSAIDs● may reduce efficacy of gemeprostand intrauterine contraceptive devic-es, increasing risk of pregnancy● increased risk of bleeding if given withoxpentifylline (also known as pentoxi-fylline)Nursing points/Cautions● suppositories provide more consis-tent control of overnight symptomsthan oral medication● suppositories are not recommendedin those with haemorrhoids or recentproctitis or rectal bleeding● gel is contraindicated in open or in-fected wounds or skin conditionssuch as eczema● see general points for NSAIDsPatient teaching and advice● patients who experience night painand/or morning stiffness should beadvised to take oral treatment duringthe day and suppositories at bedtimefor better control of symptoms● recommend that slow-release tabletsshould not be broken, crushed orchewed but swallowed whole● warn patient about symptoms of non-bacterial UTI symptoms● advise patient against using gel underan occlusive dressing● (gel) warn patient to avoid exposureto ultraviolet light (including solarium)during treatment and for 2 weeks fol-lowing therapy● advise patient that if rash appearswhen using gel, therapy should bestopped● patient should be advised to washhands after applying gel and avoidcontact with eyes or mouth● see general Patient teaching and ad-vice (p. xxiii)MEFENAMIC ACID (Ponstan)Available formCapsules: 250 mgAction● see general Actions for NSAIDs● half-life 2 hoursUse● primary dysmenorrhoea● primary menorrhagia● mild to moderate pain (e.g. dental andsoft tissue pain)Dose● (primary dysmenorrhoea) 500 mgorally 3 times daily with food fromonset of pain for usual duration ofpain OR● (primary menorrhagia) 500 mg orally3 times daily with food from onset ofmenses and continued according todoctor’s advice, not exceeding 7 days(except on doctor’s advice) OR● (other indications) 500 mg orally 3times daily with foodAdverse effects● see general Adverse effects forNSAIDs, particularly diarrhoeaInteractions/Nursing points/Cautions/Patient teaching andadvice● see general points for NSAIDs● advise patient that diarrhoea is dosedependent and disappears whenmedication is stopped● contraindicated in those who havepreviously experienced mefenamicacid-induced diarrhoeaSample chapter
    • 15ANALGESICS, NSAIDs AND DMADsMELOXICAM (Meloxibell, Meloxicam-GA, Mobic, Movalis, Movalis Capsules,Moxicam)Available formsTablets: 7.5 mg, 15 mg; Capsules:7.5 mg, 15 mgAction● selective COX-2 inhibitor● half-life 20 hours● see general Actions for NSAIDsUse● osteoarthritis, rheumatoid arthritisDose● (osteoarthritis) 7.5 mg orally dailywith food, increasing to 15 mg dailyif needed (daily maximum dose 15mg) OR● (rheumatoid arthritis) 15 mg orallydaily with food, decreasing to 7.5 mgdaily if condition allowsAdverse effects● diarrhoea, dyspepsia, abdominal pain● headache● oedemaInteractions● caution if given with sulfamethoxazoleas increased levels of either drug ispossible, increasing risk of adverseeffects● caution if given with ketoconazole,itraconazole, erythromycin, cyclospo-rin and amiodarone● increased elimination if given withcholestyramine● see also general Interactions forNSAIDsNursing points/Cautions● contains lactose, therefore contra-indicated in those with hereditarygalactose intolerance● see general points for NSAIDsMETHYL SALICYLATE (Methyl SalicylateLiniment, Cream and Ointment)Available formsCream, Liniment and OintmentAction● topical analgesicUse● relief of pain and inflammation as-sociated with rheumatic conditions,lumbago and other musculoskeletaldisordersDose● massage into affected area 2–3 timesdailyAdverse effects● acute poisoning has occurred whentaken orally● mild skin irritation, erythemaInteractions● excessive use may increase risk ofbleeding in those taking warfarin orother anticoagulantsPatient teaching and advice● patient should be advised to washhands after applying gel and avoidcontact with eyes or mouth● warn patient to avoid vigorous rub-bing● caution patient to keep medicationaway from open flameNote● contained in Arthrirub, Biosal Arthri-tis Cream, Bosisto’s Eucalyptus Rub,Deep Heat, Dencorub Extra StrengthHeat Gel, Dencorub Pain RelievingCream, Goanna Heat Cream, GoannaLiniment, Goanna Salve, Metsal HeatRub Cream and GelNAPROXEN (Inza, Naprosynpreparations, Proxen SR)Sample chapter
    • 16HAVARD’S NURSING GUIDE TO DRUGSNAPROXEN SODIUM (Anaprox,Crysanal, EazydayzTablets, Naprofem,Naprogesic, Nurolasts)Available formsTablets: 220 mg, 250 mg, 275 mg, 500mg, 550 mg; Tablets (sustained release):750 mg, 1000 mg; Suspension: 25 mg/mLAction● see general Action for NSAIDs● half-life 14 hoursUse● rheumatoid arthritis, osteoarthritis,ankylosing spondylitis● acute/chronic inflammatory pain● migraine● primary dysmenorrhoeaDose● (arthritis, spondylitis) 550–1100 mgorally daily in 2 divided doses withfood OR● (arthritis, spondylitis) 750–1000 mgorally once daily (SR) OR● (primary dysmenorrhoea) 500–550mg orally with food at the first signof pain or bleeding, then 250–275 mg6–8 hourly as required (daily maxi-mum 1250–1375 mg) OR● (primary dysmenorrhoea) 440 mgorally with food at the first sign ofpain or bleeding, then 220 mg after 12hours (daily maximum 660 mg) (220mg tablets) OR● (migraine) 825 mg orally at first sign ofimpending headache, then 275–550mg throughout day, but not before 1hour of initial dose (daily maximum1375 mg) OR● (acute inflammatory pain) initially 550mg orally with food, then 275 mg 6–8hourly (daily maximum 1375 mg) OR● (acute inflammatory pain) initially220–440 mg orally with food, then220 mg after 12 hours (daily maxi-mum 660 mg) (220 mg tablets)Adverse effects/Interactions● see general Adverse effects and Inter-actions for NSAIDsNursing points and Cautions/Patientteaching and advice● instruct patient to discontinue medi-cation 72 hours before adrenal func-tion tests● advise patients that sustained releasetablets should be taken whole, notcrushed or chewed● caution patients on sodium restrict-ed diet that tablets contain sodium(1 mEq) (Aleve)● see general points for NSAIDs● see general Patient teaching andadvice (p. xxiii)Note● Contained in Vimovo with Esomepra-zolePARACETAMOL (Duatrol SR, Dymadon,Dymadon P, Febridol, Febridol ClearEffervescent Soluble Tablets, FebridolInfant Drops, Lemsip Max, LemsipOriginal Lemon, Panadol preparations,Panamax, Paracetamol SolubleTablets, Paralgin, Perfalgan)Available formsTablets: 500 mg; Tablets (modified re-lease): 665 mg; Tablets (soluble): 250mg, 500 mg; Tablets (chewable): 120mg Caplets: 500 mg; Gel Caps: 500 mg;Suppositories: 125 mg, 250 mg, 500 mg;Sachets (powder): 500 mg, 1 g; Syrup/Suspension/Elixir: 24 mg/mL, 48 mg/mL, 120 mg/5 mL, 250 mg/5 mL; Drops:50 mg/mL, 100 mg/mL; IV solution: 10mg/mLAction● analgesic, antipyretic but has no use-ful anti-inflammatory properties● action thought to be related to prosta-glandin synthesis inhibition (via COXinhibition) in the CNSSample chapter
    • 17ANALGESICS, NSAIDs AND DMADs● half-life 1–3 hours● suitable alternative for those withaspirin allergy (including those withasthma), dyspepsia or peptic ulcer-ation or children with fever caused byviral illnessUse● mild to moderate pain● headache, migraine, tension head-ache, sinus pain● muscle ache● arthritis● toothache● cold and flu symptoms● feverDose● 0.5–1 g orally 3–4 hourly as required(up to 4 g/day) OR● 1330 mg orally 6–8 hourly as required(up to 4 g/day) (modified release tab-lets) OR● 0.5–1 g rectal suppository 4–6 hourlyas required (up to 4 g/day) OR● (≥ 50 kg) 1 g IV up to 4 times daily (upto 4 g/day) OR● (< 50 kg) 15 mg/kg IV up to 4 timesdaily (up to 4 g/day)Adverse effects● (rarely) nausea, dyspepsia, allergic orhaematological reaction● hepatic necrosis (10–15 g or more),renal dysfunction● (IV) nausea, vomiting, diarrhoea, dys-pepsia, increase in liver enzymes,injection site painInteractions● absorption rate may be increased bymetoclopramide● prolonged dosage may require reduc-tion in anticoagulant dose● large or chronic doses of paracetamolincrease the likelihood of hepatotox-icity if given with concurrent use ofalcohol or antiepileptic drugs● may decrease clearance of busulfan● products containing paracetamolshould not be given together (e.g. oraland IV) to avoid risk of overdose andhepatic damage● (IV) probenecid reduces clearance● (IV) metabolism may be increased(therefore increasing level of hepa-toxic metabolites) by barbiturates,anticoagulants, isoniazid, zidovudine,amoxycillin and clavulanic acid, car-bamazepine and phenytoinNursing points/Cautions● administer alone IV● IV infusion given over 15 minutes● IV solution has slight yellow colour● IV administration should be changedto oral administration as soon aspracticable● overdose symptoms: anorexia,nausea, vomiting, abdominal pain,hypotension, lethargy, sweating,confusion, hepatic necrosis/failure(jaundice, hypoglycaemia, metabolicacidosis)● symptoms of overdose in first 48hours may not reflect potential seri-ousness, as symptoms of liver failuremay not manifest for at least 72 hours● caution if used in those with renaldysfunction or glucose-6-phosphatedehydrogenase deficiency as haemo-lytic anaemia may result● safe to use during pregnancy andbreastfeeding at analgesic doses● (IV) caution if used in those with dehy-dration, hypovolaemia, chronic mal-nutrition (including anorexia, bulimiaor cachexia) or chronic alcoholism(> 3 drinks/day)● contraindicated in those with liver dis-ease/failurePatient teaching and advice● instruct patient to dissolve efferves-cent and soluble preparations in ½–1glass of water for more rapid absorp-tion● patient should be cautioned regardingrisk of overdoseSample chapter
    • 18HAVARD’S NURSING GUIDE TO DRUGS● caution if using paracetamol prod-ucts containing sodium in those witha salt-restricted diet (e.g. PanadolSoluble, Panadol Rapid)Note● not recommended for infants under1 month of age● after taking blood for paracetamolassay, overdose should be treatedpromptly (within 10 hours) with acti-vated charcoal and sorbitol or gastriclavage to reduce gastric absorptionand with IV acetylcysteine (Parvo-lex) to protect against liver damage(see Chelating agents, antidotesand antagonists) if 10–15 g or moreof paracetamol has been ingested.Liver tests are recommended at startof overdose management, then daily● contained in Anagraine, Capadex,Codalgin, Codalgin Forte, CodalginPlus, Codapane, Codapane Forte,Codral Original Cold & Flu + CoughDay and Night Capsules, CodralOriginal Cold & Flu Tablets, CodralOriginal Day and Night Cold & FluTablets, Codral 4 Flu Tablets, Com-farol Forte, Demazin Cold and FluTablets, Demazin Cough, Cold andFlu Tablets, Demazin Day & NightCold & Flu, Demazin PE Cold & FluRelief Day & Night Tablets, DemazinPE Cold & Flu Relief Tablets, DiGe-sic, Dimetapp Cough Cold and FluDay Relief Liquid Caps, DimetappCough Cold and Flu Night Relief Liq-uid Caps, Dimetapp Cough Cold andFlu Day and Night Liquid Capsules,Dimetapp Daytime/Nightime LiquidCapsules, Dimetapp PE Sinus Day+ Night Tablets, Dimetapp PE SinusPain + Allergy Tablets, Dimetapp PESinus Pain Tablets, Dolaforte, FebridolPlus, Fiorinal, Fiorinal-Dental, LemsipPharmacy Flu Strength Nightime,Lemsip Pharmacy Flu Strength Day-time, Logicin Flu Strength Day andNight Tablets, Maxydol, Mersyndol,Mersyndol Day Strength, MersyndolForte, Metomax, Norgesic, Painstopfor Children Day-Time Pain Relief,Painstop Night-Time Pain Relief,Panadeine Extra, Panadeine, Pana-deine Forte, Panadol Extra, PanadolFlu Strength PE Day & Night, PanadolSinus Relief PE, Panadol Sinus Re-lief Original Formula, Panadol SinusRelief Day & Night Original Formula,Panalgesic, Panamax Co, Paradex,Prodeine 15, Prodeine Forte, Ro-bitussin Cold & Flu + DecongestantTablets, Robitussin Head Cold & Si-nus Tablets, Sinutab Sinus and PainRelief, Sinutab Sinus, Allergy and PainRelief, Sudafed PE Sinus Day & NightRelief Tablets, Sudafed PE Sinus + Al-lergy & Pain Relief, Sudafed PE Sinus& Pain Relief, Sudafed Sinus + Allergy& Pain Relief Tablets, Sudafed Sinus+ Pain Relief, Sudafed Sinus Day +Night Relief Tablets, Tensodeineany combination products containingdextromethorphan or pseudoephedrineare banned in sportPARECOXIB SODIUM (Dynastat)Available formVial: 40 mgAction● selective COX-2 inhibitor● rapidly converted to valdecoxib,which is the active component● see general Actions for NSAIDs● onset of analgesia 7–14 minutes,peak reached within 2 hours, durationof action 6–24 hours, half-life about8 hoursUse● postoperative pain (single dose)Dose● 40 mg IV or IM as once-only doseAdverse effects● hypotension, hypertension, dizzinessSample chapter
    • 19ANALGESICS, NSAIDs AND DMADs● peripheral oedema● hypoaesthesia● nausea, vomiting, abdominal pain,dyspepsia, constipation● hypokalaemia● insomnia● pharyngitis, respiratory insufficiency● pruritus, increased sweating● oliguriaInteractions● increased serum levels may occur ifgiven with ketoconazole or flucon-azole● caution if given with warfarin, there-fore international normalised ratio(INR) should be closely monitored● may decrease clearance of lithium,therefore blood levels should beclosely monitored● caution if given with ACE inhibitorsNursing points/Cautions● reconstituted using sodium chloride0.9% 2 mL (40 mg) or 1 mL (20 mg)● administer alone● incompatible with lactated Ringer’sor glucose 5% in lactated Ringer’sas precipitate will form and thereforeshould not be reconstituted with thesefluids or added into IV lines with thesefluids already running● contraindicated in those with knownallergy to sulfonamides● see general points for NSAIDsPHENAZONEAction● topical analgesicUse● acute otitis media (see Ear section ofEye, ear, nose and throat agents)Note● contained in Auralgin Otic, Ear Clearfor Ear Ache ReliefPIROXICAM (Feldene, Feldene D,Feldene Gel, Mobilis, Mobilis D)Available formsCapsules: 10 mg, 20 mg; Capsules (dis-persible): 10 mg, 20 mg; Tablets: Gel: 5mg/gAction● see general Actions for NSAIDs● half-life 36–45 hoursUse● rheumatoid arthritis, osteoarthritis,ankylosing spondylitis● acute soft tissue injuriesDose● 10–20 mg orally as a single daily doseOR● 1 g (3 cm of gel) to affected area 3–4times daily for up to 2 weeksAdverse effects● (gel) mild skin irritation, transient skindiscolouration● see general points for NSAIDsInteractions● see general points for NSAIDsNursing points/Cautions● once-daily dose required because oflong plasma half-life (capsules)● see general points for NSAIDsPatient teaching and advice● patient should be advised to washhands after applying gel and avoidcontact with eyes or mouth● instruct patient to dissolve dispersibletablets in not less than 50 mL of water● caution patient to not cover gel withocclusive dressing● warn patient that gel should not beapplied to broken, irritated or infectedskin● advise patient that gel should becompletely rubbed in to prevent skindiscolouration or staining of clothesSample chapter
    • 20HAVARD’S NURSING GUIDE TO DRUGS● see Patient teaching and advice forNSAIDs and general Patient teachingand advice (p. xxiii)SULINDAC (Aclin)Available formsTablets: 100 mg, 200 mgAction● see general Action for NSAIDs● prodrug that has a biologically activemetabolite● half-life 7–8 hours; half-life of activemetabolite 16.4 hoursUse● rheumatoid arthritis● osteoarthritis● ankylosing spondylitis● acute gouty arthritis● acute or chronic pain with an inflam-matory componentDose● 400 mg orally daily or in 2 divideddoses with food or milkAdverse effects● urine discolouration● see general points for NSAIDsInteractions● see general points for NSAIDsNursing points and Cautions/Patient teaching and advice● if given as a single dose, patient shouldbe advised to take in the evening● if given for acute gouty arthritis, treat-ment is usually for 7 days● see general points for NSAIDs● see Patient teaching and advice forNSAIDs and general Patient teachingand advice (p. xxiii)TIAPROFENIC ACID (Surgam)Available formTablets: 300 mgAction● see general Actions for NSAIDs● half-life 2–3 hoursUse● rheumatoid arthritis, osteoarthritisDose● 300–600 mg orally daily in divideddosesAdverse effects● see general Adverse effects forNSAIDs (p. 2)● non-bacterial cystitis (bladder pain,dysuria, haematuria, increased mic-turition and frequency)Interactions/Nursing points/Cautions/Patient teaching andadvice● see general points for NSAIDs● before starting therapy, patientsshould be assessed for any urinarysymptoms● patients should be advised to reportany urinary symptoms promptly totheir doctor● urinary symptoms usually resolvequickly when medication is stopped● advise patients to take tablets withplenty of fluids unless otherwise con-traindicated● not recommended in those with ac-tive bladder or prostate disease/symptoms, recurrent urinary tractdisordersDISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)Arthritis is a term used to describe dis-ease of the joints with common formsincluding rheumatoid arthritis (RA),osteoarthritis, juvenile idiopathic ar-thritis and spondylarthropathies (e.g.ankylosing spondylitis). RA is the mostSample chapter
    • 21ANALGESICS, NSAIDs AND DMADscommon autoimmune disease in Austra-lia, affecting about 1% of the population(AIHW, 2011a).RA is characterised by inflamma-tion and thickening of the synovialmembrane (synovitis). This unrelentinginflammation leads to destruction of tis-sue, cartilage erosion and, at times, rup-turing of tendon fibres (AIHW, 2011a).Most commonly, the small joints of thehands and feet are involved. RA is arapidly progressing disease which oftentakes an erratic and unpredictable course(AIHW, 2011). Even with treatment, RAsometimes still progresses, with destruc-tion of the affected joints, deformity,disability and possible reduction in lifeexpectancy (RACGP, 2009). Early diag-nosis and treatment with DMARDs isessential in slowing disease progressionand achieving remission. There is someevidence to suggest that early use ofDMARDs is associated with an improve-ment in long-term functional outcomes(RACGP, 2009).The DMARDs are a heterogeneousgroup of drugs which are anti-inflamma-tory and immune-suppressing in nature(AIHW, 2011). Although mainly used totreat RA, they are also used to treat otherautoimmune diseases such as Crohn’sdisease, psoriatic arthritis and systemiclupus erythematosis (SLE). DMARDsare broken up into two groups – the ‘con-ventional’ DMARDs (e.g. methotrexate,gold, sulfasalazine) and the biologicalDMARDs. These biological DMARDs(etanercept, infliximab, adalimumab,anakinra) are a newer group that targetpro-inflammatory cytokines involved injoint destruction and although expen-sive, are being used more commonlyin the treatment of RA (AIHW, 2011).Onset of action of the DMARDs is oftenslow, taking weeks to months before clin-ical improvement is apparent. They areused alone, or in combination with otherDMARDs, NSAIDs and/or corticoste-roids. Methotrexate is now considered tobe first line treatment of RA, comparedto earlier management which consistedof NSAIDs, with DMARDs only beingadded into the regimen when damage tothe joint had occurred (RACGP, 2009).Tumour necrosis factor alpha (TNF-α)is important for both immune respon-sibility and host defences and thereforeTNF-α antagonist use predisposes theuser to a range of infections (especiallytuberculosis), particularly in the first24 months of therapy. These biologicalagents should also be avoided in thosewith chronic hepatitis B and C if liverpathology is present, upper respiratorytract infections and fever, skin ulcerswhich have not healed, active herpeszoster infection or life-threatening fun-gal infection (Saag et al, 2008, cited inBryant & Knights, 2011).Adjunctive treatment for RA shouldalso include physiotherapy, occupationaltherapy, exercises and, most importantly,patient education and access to supportservices (e.g. Arthritis Foundation).ABATACEPT (Orencia)Available formVial: 250 mgAction● modulates key co-stimulatory sig-nal required for full activation ofT-lymphocytes which are found in thesynovium of those with RA● half-life 8–25 daysUse● moderate to severe rheumatoid arthri-tis (with methotrexate) (unresponsiveto other DMARDs)Sample chapter
    • 22HAVARD’S NURSING GUIDE TO DRUGS● moderate to severe active polyarticu-lar juvenile idiopathic arthritis (unre-sponsive to other DMARDs) (alone orwith methotrexate)Dose● (rheumatoid arthritis) (patient weight< 60 kg) 500 mg, (60–100 kg) 750 mgor (> 100 kg) 1 g IV over 30 minutesgiven 2 and 4 weeks after initial infu-sion, then monthly OR● (polyarticular juvenile idiopathic ar-thritis) (patient weight < 75 kg) 10mg/kg IV over 30 minutes given 2and 4 weeks after initial infusion, thenmonthly (if patient weight is > 75 kg,regimen for rheumatoid arthritis is fol-lowed (maximum 1 g))Adverse effects● headache, dizziness, fatigue, asthenia● nausea, abdominal pain, diarrhoea,dyspepsia● infusion-related reaction (dizziness,hypertension, nausea, headache)● infection (lower respiratory, urinarytract, upper respiratory), rhinitis, her-pes simplex● hypertension, flushing● cough● rash● abnormal liver function● (uncommon) hypersensitivityInteractions● not recommended with tumour necro-sis factor (TNF) inhibitors, rituximabor anakinra● not recommended with or within 3months of live attenuated vaccine● may cause a falsely elevated bloodglucose reading on the day of infu-sion (if test strips contain glucosedehydrogenase pyrroloquinoline-quinone as this reacts with maltosein the solution)Nursing points/Cautions● patients should be screened for anysigns of infection before starting ther-apy. This should include screening forhepatitis B and tuberculosis (clinicalhistory, chest X-ray, skin tuberculintest). If latent tuberculosis is diag-nosed, it should be treated with ap-propriate antimycobacterial agentsbefore starting therapy● (polyarticular juvenile idiopathic ar-thritis) vaccinations should be up-to-date before starting therapy● dosage is dependent on body weight● reconstitute by gently injecting Waterfor Injection into vial, avoiding vigor-ous agitation or shaking● after reconstitution, vial should bevented with a needle to dispel anyfoam formed● reconstituted solution should be clearand colourless to pale yellow● reconstituted solution should thenbe added to a 100 mL bag of 0.9%sodium chloride, first removing theequivalent amount of sodium chloride(e.g. if 4 vials have been reconstitutedequalling 40 mL, then 40 mL of so-dium chloride should be removed be-fore adding the reconstituted solution)● administer alone● contains 8.6 mg sodium per vial,which may need to be considered forthose on a sodium-controlled diet● patients should be monitored dur-ing and after infusion for any signs ofinfusion-related events● patient should be monitored for anysigns of infection and therapy dis-continued if they develop a seriousinfection● caution if used in those with chronicobstructive pulmonary disease asrespiratory symptoms (cough, dys-pnoea, rhonchi) may be exacerbated● contraindicated in those with severeinfections, including sepsis and tu-berculosisPatient teaching and advice● tell patient that IV infusion will take 30minutesSample chapter
    • 23ANALGESICS, NSAIDs AND DMADs● patients requiring blood glucosemonitoring should be warned thatfalsely elevated levels may occurpost-infusion● advise patients not to drive or oper-ate machinery if they experience diz-ziness● see general Patient teaching and ad-vice (p. xxiii)not recommended during pregnancy orbreastfeedingADALIMUMAB (Humira)Available formsPrefilled syringe: 20 mg/0.4 mL, 40mg/0.8 mL; Prefilled pen: 40 mg/0.8 mLAction● recombinant monoclonal antibody(IgG1) that neutralises activity of tu-mour necrosis factor (TNF). (TNFis involved in inflammatory and im-mune responses and found in highlevels in the synovial fluid of thosewith RA. It is thought to be involved inboth joint inflammation and erosion.Raised TNF levels are also found inthose with psoriatic arthritis, psoriaticplaques and ankylosing spondylitis)● long half-life 10–20 daysUse● rheumatoid arthritis● psoriatic arthritis (unresponsive toother DMARDs)● ankylosing spondylitis● polyarticular juvenile idiopathic arthri-tis (over 4 years)● psoriasis● Crohn’s disease (inadequate re-sponse to conventional therapies orintolerant/unresponsive to infliximab)(see Gastrointestinal agents (Miscel-laneous))Dose● (rheumatoid arthritis) 40 mg SC fort-nightly (or weekly if not given concur-rently with methotrexate) OR● (psoriatic arthritis, ankylosing spon-dylitis) 40 mg SC fortnightly OR● (psoriasis) initially 80 mg SC, then 1week later 40 mg SC, repeated fort-nightly OR● (polyarticular juvenile idiopathic ar-thritis) 20 mg SC fortnightly (weight15 kg to less than 30 kg) or 40 mgSC fortnightly (weight 30 kg or more)Adverse effects● injection site reaction (erythema, itch-ing, swelling)● rash, pruritus, urticaria, dermatitisherpes simplex, bruising, dermatitis● cough, sinusitis, dyspnoea, asthma● visual impairment● musculoskeletal pain, muscle spasm● headache, migraine, vertigo● paraesthesia, sciatica● tachycardia, hypertension● depression, anxiety, insomnia● nausea, vomiting, abdominal pain,dyspepsia, elevated liver enzymes● haematuria, renal impairment● benign neoplasm, skin cancer● leucopenia, thrombocytopenia, leu-cocytosis● hyperlipidaemia, hyperkalaemia, hy-pocalcaemia, hyperglycaemia● impaired healing● infection (upper and lower respiratory,urinary tract, soft tissue, reproductivetract, ear and oral, fungal)● (uncommonly) reactivation of tuber-culosis, development of autoanti-bodies, lupus-like syndrome, seriousallergic reactionInteractions● not recommended with live attenu-ated vaccines● contraindicated with anakinra● not recommended with abataceptSample chapter
    • 24HAVARD’S NURSING GUIDE TO DRUGSNursing points/Cautions● before starting therapy, patientsshould be:– screened for any signs of infection.This should include screening forhepatitis B and tuberculosis (TB)(clinical history, chest X-ray, skintuberculin test) as these can be-come reactivated. If latent TB isdiagnosed, it should be treatedwith appropriate antimycobacteri-al agents before starting therapy. Ifactive TB is found, therapy shouldnot be started; and– examined for non-melanoma skincancer● rotate injection sites (thigh or abdo-men), avoiding skin that is reddened,bruised, tender or hard● do not mix with other agents in thesyringe● patients may be taught to self-administer medication SC. Theyshould be educated about rotation ofsites, injection technique, storage re-quirements and safe disposal of usedneedles● (polyarticular juvenile idiopathic ar-thritis) all immunisations should beup-to-date before starting therapy● therapy should be stopped if any newserious infection or lupus-like symp-toms develop● needle covers of prefilled syringescontain latex and should not be han-dled by or administered to anyonewith a latex sensitivity● if undergoing surgery, patient shouldbe closely monitored for any signs ofinfection● caution if used in those who haverecently been diagnosed with CNSdemyelinating disease, on concurrentimmunosuppressive therapy (as thereis an increased risk of infection) orheart failure (as it may be worsened)● contraindicated in those with severeinfections (including active tuberculo-sis) or moderate to severe heart failurePatient teaching and advice● patients should be counselled toimmediately seek medical advice ifthey develop persistent cough, lossof weight or low-grade fever (signsof TB)● ask patient if he/she has a latex sen-sitivity as needle covers of prefilledsyringes contain latex● women of childbearing age should beadvised to use adequate contracep-tion during therapy● patients may be taught to self-ad-minister medication SC. Informationshould include:– checking expiry date before usingand not giving injection if syringehas been out of the refrigerator formore than 12 hours– allowing syringe to come to roomtemperature before administration– gently inverting, not shaking, sy-ringe before administration. Ifsolution looks frothy, it should beallowed to rest until it clears beforeusing– giving SC injection under the skinusing the technique demonstratedby the doctor/nurse. Sites shouldbe rotated between abdomen andthigh to prevent discomfort– giving SC injection at the sametime every day– protecting prefilled syringes fromlight before use and storing themat 2–8°C, but not frozen– safe disposal of used syringenot recommended during pregnancyANAKINRA (Kineret)Available formPrefilled syringe: 100 mg/0.67 mLAction● recombinant, non-glycosylated hu-man interleukin-1 receptor antagonistSample chapter
    • 25ANALGESICS, NSAIDs AND DMADs(interleukin-1 is thought to play a partin both inflammatory and immuno-logical responses, including the deg-radation of cartilage and stimulationof bone resorption)● half-life 4–6 hoursUse● active rheumatoid arthritis (with meth-otrexate) that is unresponsive to otherDMARDsDose● 100 mg daily SCAdverse effects● increased incidence of infections (in-cluding cellulitis, pneumonia, bone/joint)● mild injection site reaction (erythema,ecchymosis, inflammation, pain)● headache, dizziness, insomnia● nausea, diarrhoea, abdominal pain,dyspepsia● hypertension● limb pain, back pain, myalgia● increased risk of lymphomaInteractions● contraindicated with TNF-alpha an-tagonist drugs (e.g. etanercept, inf-liximab)● should not be given with live attenu-ated vaccinesNursing points/Cautions● baseline blood counts (WBC, plate-lets, absolute neutrophil count)should be measured before startingand monitored regularly throughouttherapy● needle covers of prefilled syringescontain latex and should not be han-dled by or administered to anyonewith a latex sensitivity● caution if used in those with a knownhistory of recurring infections or con-ditions that may predispose them toinfection● not recommended in those with se-vere renal impairment● contraindicated in those with knownhypersensitivity to E. coli-derivedproductsPatient teaching and advice● patients may be taught to self-administer ankakinra SC. They shouldbe educated about rotation of sites,injection technique, storage require-ments and safe disposal of usedneedles● patients can be instructed to self-administer anakinra subcutaneously.See patient teaching and advice foradalimumab for specific subcutane-ous injection advice● see also general Patient teaching andadvice (p. xxiii)should only be used during pregnancy ifbenefits outweigh potential riskscaution if used during breastfeedingAURANOFIN (Ridaura)Available formTablets: 3 mgAction● synthetic gold complex that decreas-es inflammation, levels of rheumatoidfactor and elevated immunoglobulinlevels● may slow progression of joint erosion● anti-inflammatory action● clinical improvement seen in 3–4months after initiation of therapy● elimination half-life increased fromabout 17 days to 26 days after 6months of therapyUse● rheumatoid arthritis that is unrespon-sive or intolerant to NSAIDsDose● initially 6 mg orally daily with food,increasing to 9 mg in 3 divided dosesif neededSample chapter
    • 26HAVARD’S NURSING GUIDE TO DRUGSAdverse effects● diarrhoea, constipation, flatulence● anorexia, nausea, vomiting, abdomi-nal pain/cramps, dyspepsia, distortedtaste, stomatitis, glossitis● conjunctivitis● rash, pruritus, hair loss● phototoxicity● blood dyscrasia● haematuria, proteinuria, blood ureaand serum creatinine, nephrotoxicity● increased liver enzymesInteractions● not recommended with other agentscausing blood dyscrasias or bonemarrow depression● caution if used with warfarin, cloni-dine or dextropropoxypheneNursing points/Cautions● diabetes, heart failure or hypertensionshould be controlled/corrected beforestarting therapy● GI symptoms are dose-related andthose with low body weight are atgreatest risk● auranofin-induced diarrhoea can becontrolled by decreasing dose● renal and liver function tests, bloodcount (with differential white cellcount), haemoglobin, complete uri-nalysis (with urinary protein levels)should be performed before startingtherapy● monthly blood counts (with differen-tial white cell count), platelet countand urinary protein levels are recom-mended● ophthalmological examination is rec-ommended periodically throughouttherapy● overlap or washout period not re-quired if transferring from injectablegold preparations● caution if used in those with inflam-matory bowel disease or history ofatopy● contraindicated in those with previoustoxicity or sensitivity to gold or heavymetals, liver/kidney disease, severechronic dermatitis, bone marrow de-pression or haematological disordersor gold-induced pulmonary fibrosis ornecrotising enterocolitisPatient teaching and advice● instruct patient to avoid exposure tostrong direct sunlight● patient should be advised to immedi-ately report any metallic taste (sign ofimpending toxicity) or pruritus (earlysign of intolerance) to doctor● tablets should be protected from sun-light● caution women of childbearing ageto use adequate contraception duringand for at least 6 months after stop-ping therapy because gold is slowlyexcreted from the body, which mayhave negative effects on a develop-ing fetus● see also general Patient teaching andadvice (p. xxiii)not recommended during pregnancysecreted in breast milk, therefore notrecommended during breastfeeding;because gold is slowly excreted fromthe body after stopping therapy, thisshould be taken into account if a wom-an wants to breastfeedCYCLOSPORIN (Neoral, Sandimmun)Available formsCapsules: 10 mg, 25 mg, 50 mg, 100 mg;Oral solution: 100 mg/mL; Ampoule: 50mg/mL, 250 mg/5 mLAction● potent immunosuppressive agent● thought to act by blocking both lym-phocytes and antigen-triggered lym-phokine release by activated T cellsSample chapter
    • 27ANALGESICS, NSAIDs AND DMADs● half-life 6.3 hours, increasing to 20.4hours in those with severe liver dis-easeUse● prevention of graft versus host dis-ease in organ transplantation (seeImmunomodifiers)● induction and/or maintenance of re-mission in nephrotic syndrome (whenother therapies have been ineffectiveor inappropriate and renal function isstill intact)● severe, active rheumatoid arthritis(when other therapies have been in-effective or inappropriate)● severe psoriasis (when other thera-pies have been ineffective or inap-propriate)● severe atopic dermatitis (when othertherapies have been ineffective or in-appropriate)Dose● (rheumatoid arthritis) 3 mg/kg dailyorally in 2 divided doses for first 6weeks of therapy (which may becontinued to 12 weeks for full effec-tiveness). If no clinical response in4–8 weeks, dose may be increasedby 0.5–1.0 mg/kg/day at 1–2-monthintervals to 5 mg/kg/day maximum.If the patient has been stable forat least 3 months, the dose maybe decreased by 0.5 mg/kg/day at1–2-month intervals to achieve thelowest effective dose OR● (psoriasis) 2.5 mg/kg orally daily in 2divided doses, increasing to 5 mg/kg if there is no clinical response in4 weeks OR● (nephrotic syndrome) 2.5–5 mg/kg/day, decreasing to lowest effectivedose (maintenance) OR● (atopic dermatitis) initially 2.5–5 mg/kg orally daily in 2 divided doses, re-ducing dose gradually when satisfac-tory response has been achievedAdverse effects● hypertension● fluid retention and oedema● hyperkalaemia, hyperuricaemia, hy-pomagnesaemia, hyperlipidaemia● weight increase● tremor, fatigue, burning sensation inhands and feet (initially)● muscle cramps, myalgia● headache, paraesthesia, convulsions● hirsutism, rash● dysmenorrhoea/amenorrhoea (revers-ible)● gingival hypertrophy● anorexia, nausea, vomiting, diar-rhoea, abdominal pain● anaemia, increased susceptibility toor aggravation of infection● impaired renal function, hepatic dys-function, acute pancreatitis● increased risk of malignancy● (IV) anaphylactoid reactionsInteractions● increased risk of nephrotoxicity whenlow dose cyclosporin is given withNSAIDs requiring regular monitoringof kidney function● may increase serum levels of siroli-mus and everolimus● increased serum creatinine may occurif given with sirolimus or everolimus● increased risk of nephrotoxicity ifgiven with tacrolimus● may increase bioavailability of diclof-enac● caution if given with lercanidipine asserum level of both agents may beincreased● increased risk of hyperkalaemia ifgiven with potassium containing orpotassium sparing medications● caution if given with ACE inhibitorsor angiotensin II receptor antagonists● not recommended with UVB irradia-tion or PUVA chemotherapy becauseof increased risk of skin cancer de-velopmentSample chapter
    • 28HAVARD’S NURSING GUIDE TO DRUGS● reversible renal impairment may oc-cur if given with fenofibrate or otherfibric acid derivatives● not recommended with other knownnephrotoxic drugs such as aminogly-cosides, amphotericin, ciprofloxacin,colchicine, histamine H2 antagonists,melphalan, methotrexate, NSAIDs,trimethoprim and vancomycin● blood levels (and associated toxic-ity) may be increased if given withallopurinol, amiodarone, azole an-tifungal agents, cholic acid, colchi-cine, danazol, diltiazem, doxycycline,grapefruit juice, imatinib, macrolideantibiotics, metoclopramide, meth-ylprednisolone (high dose), oralcontraceptives, protease inhibitors,verapamil and voriconazole● increased risk of muscle toxicity(muscle pain, weakness, myositis,rhabdomyolysis) if given with ator-vastatin, colchicine, pravastatin orsimvastatin because of decreasedclearance● blood levels may be decreased ifgiven with barbiturates, carbamaze-pine, ciprofloxacin, isoniazid, octreo-tide, orlistat, phenytoin, rifampicin,St John’s wort, sulfamethoxazole/trimethoprim (IV)● not recommended with thiazide orloop diuretics because of increasedrisk of pre-renal azotaemia, worsen-ing hyperuricaemia, glucose intoler-ance or hyperlipidaemia● not recommended with live attenu-ated vaccines● not recommended with alcohol● increased risk of gingival hyperplasiaif given with nifedipine or amlodipine● may decrease clearance (and there-fore increase blood levels) of colchi-cine, digoxin, etoposide, predniso-lone and statins, and increasing riskof toxicityNursing points/Cautions● capsules and oral solution are bio-equivalent● any infections should be identifiedand treated before starting therapy● adverse effects are more commonwhen cyclosporin is used for trans-plant patients than when used forother conditions because the doseis higher● (nephrotic syndrome) dose is depen-dent on renal function. If improve-ment is not seen in 12 weeks, therapyshould be stopped● (nephrotic syndrome) renal biopsy isrecommended if therapy continuesfor 12 months● (psoriasis) any unusual lesions shouldbe biopsied before starting therapy todecrease risk of cancer occurring● (psoriasis) if there is no improvementwithin 6 weeks of therapy at 5 mg/kg/day, therapy should be stopped● (atopic dermatitis) lymphadenopathyshould be monitored during therapy.If lymphadenopathy is present afterskin improves with therapy, a biopsyis recommended to rule out lympho-ma● blood pressure should be monitoredregularly throughout therapy andhypertension treated with appropri-ate antihypertensive medication ifit occurs. However, diuretic therapyshould be avoided. If hypertensioncannot be controlled, cyclosporintherapy should be stopped● blood lipids should be measuredbefore starting therapy and after 4weeks of therapy. If lipids increase,dose should be decreased and a fat-reduced diet started● blood concentration levels neednot be measured in non-transplantpatients unless indicated by risk ofadverse reactions or potential druginteraction● discontinue therapy if there is noimprovement in 6 months whereSample chapter
    • 29ANALGESICS, NSAIDs AND DMADsmaximum tolerable dose has beenachieved for 3 months● creatinine levels should be measuredtwice before and every 2 weeksduring the first 3 months and thenmonthly. Doses should then be ad-justed accordingly. Therapy shouldstop if reducing the dose does not re-duce creatinine levels within 1 month● creatinine levels should be measuredmore frequently when the dose of cy-closporin is increased or if the patientis taking NSAIDs concurrently● serum potassium levels should bemonitored regularly, as should serumuric acid levels in high-risk patients(e.g. gout) and serum magnesium (ashypomagnesaemia increases risk ofneurotoxicity)● changes between brands should bedone carefully. Cyclosporin blood lev-el, serum creatinine level and bloodpressure should be measured at 2,4 and 8 weeks (or within 4–7 days ifused for transplant) after changeover.If blood pressure or creatinine levelsare greater than the pre-changeoverlevels, decreasing the dose is recom-mended● (oral solution) 0.1 mL solution = 10 mgcyclosporin● (non-transplant use) contraindicatedin those with uncontrolled hyperten-sion or infection, primary or secondaryimmunodeficiency, impaired baselinerenal function with serum creatininegreater than 200 micromol/L (ne-phrotic syndrome use), any renal im-pairment (other uses), or any existingmalignant or premalignant conditionsPatient teaching and advice● advise patients to avoid drinking al-cohol while taking cyclosporin, espe-cially red wine● instruct patients to take doses 12hours apart at the same time eachday● caution patients to swallow capsuleswhole, with or without food● tell patients that oral solution comeswith two syringes (1 mL and 4 mL).The 1 mL syringe should be used fordoses less than or equal to 1 mL,while the 4 mL syringe is used fordoses between 1 mL and 4 mL● instruct patients to dilute oral solutionof cyclosporin with apple or orangejuice (not grapefruit) or soft drink andstir well before drinking immediately.Glass should be rinsed with morejuice or soft drink to ensure wholedose is taken● warn patient to avoid grapefruit juiceduring therapy● instruct patient that the dose-dis-pensing syringe should not comeinto contact with juice or soft drinkand should be wiped clean, not rinsedwith water or other fluids● patients should be advised to avoidfoods high in potassium, and potassi-um-containing or potassium-sparingmedications to avoid an increase inpotassium levels● counsel patients to avoid excessiveunprotected sun exposure due to in-creased risk of skin cancer and weara hat, 30+ sunscreen and protectiveclothing if sun exposure cannot beavoided● educate patient regarding care ofteeth and gums during therapy● instruct patient to discard solutionafter 2 months of opening● advise patients that oral solutionshould be stored in a cool dark place(20–25°C), but not refrigerated. Oilycomponents of cyclosporin maysolidify below 20°C and a jelly-likesubstance may also occur. This is re-versible at warmer temperatures andit does not affect the safety or efficacycyclosporin is generally not recom-mended during pregnancy or breast-feedingSample chapter
    • 30HAVARD’S NURSING GUIDE TO DRUGSETANERCEPT (Enbrel)Available formsVial: 25 mg; Prefilled syringe: 50 mg/1 mL; Autoinjector: 25 mg/0.5 mLAction● neutralises activity of tumour necrosisfactor (TNF) (TNF is involved in inflam-matory and immune responses and isfound in high levels in synovial fluid ofthose with rheumatoid arthritis. It isthought to be involved in both joint in-flammation and erosion. Raised TNFlevels are also found in those withpsoriatic arthritis, psoriatic plaquesand ankylosing spondylitis)● reaches maximum concentration in24–96 hours● half-life approximately 80 hoursUse● rheumatoid arthritis that is unrespon-sive to other DMARDs● active polyarticular-course juvenilechronic arthritis that is unresponsiveto other DMARDs● psoriatic arthritis that is unresponsiveto other DMARDs● active ankylosing spondylitis● moderate to severe chronic plaquepsoriasisDose● 50 mg SC weekly or 25 mg SC twiceweekly 3–4 days apart OR● (plaque psoriasis) 50 mg SC weeklyor 25 mg SC twice weekly 3–4 daysapart. Dose may be increased to50 mg SC twice weekly for up to12 weeks if necessary, then reducedAdverse effects● injection site reaction (erythema, itch-ing, pain, swelling)● upper respiratory infection, non-upperrespiratory infection, rhinitis, pharyn-gitis, cough, sinusitis, bronchitis● other infection (cystitis, cellulitis, sep-tic arthritis)● headache, dizziness, asthenia● fever● abdominal pain, dyspepsia● rash, pruritus● antinuclear antibody development,allergic reactions● (rare) worsening congestive heart fail-ure, pancytopeniaInteractions● contraindicated with interleukin-1antagonists (e.g. anakinra)● not recommended with abatacept● not recommended with live attenu-ated vaccinesNursing points/Cautions● all patients should be assessed be-fore, during and after treatment forany signs of infection, which may in-clude active or latent tuberculosis orhepatitis B or C● reconstitute by gently injecting Waterfor Injection into vial, avoiding vigor-ous agitation or shaking● clear and colourless solution shouldresult within 10 minutes of reconsti-tution● solution should not be filtered, norused if discoloured, cloudy or con-taining particulate matter● use within 6 hours of reconstitution● rotate injection sites, avoiding skinthat is reddened, bruised, tender orhard or within 3 cm of previous injec-tion sites● administer alone● solution in prefilled syringe or autoin-jector should be clear, colourless orpale yellow with no visible particles● prefilled syringes (with needle coverintact) or autoinjector should be al-lowed to reach room temperaturebefore being administered● needle covers of prefilled syringescontain latex and should not be han-dled by or administered to anyonewith a latex sensitivity● therapy should be stopped if new,serious infection developsSample chapter
    • 31ANALGESICS, NSAIDs AND DMADs● vials should be refrigerated● caution if used in those with diabetesas there is an increased risk of hypo-glycaemia, necessitating a decreaseddose in antidiabetic medication● caution if used in those with a his-tory of blood dyscrasias, infectionor congestive heart failure or with arecent diagnosis of CNS demyelinat-ing disease● not recommended in those with alco-holic hepatitis● contraindicated in those with or at riskof serious active infectionPatient teaching and advice● inform patient that injection site reac-tion reduces after initial 4 weeks● patients may be taught to self-ad-minister medication SC. They shouldbe educated about rotation of sites,injection technique, storage require-ments and safe disposal of usedneedles● needle covers of prefilled syringescontain latex and should not be han-dled by or administered to anyonewith a latex sensitivity● patients should be advised to im-mediately report any persistent fever,sore throat, bruising or bleeding● if patient has diabetes, he/she shouldbe instructed to monitor blood glu-cose levels closely as etanerceptmay cause hypoglycaemia. Dose ofantidiabetic medications may need tobe adjusted accordingly● see general Patient teaching andadvice (p. xxiii)use during pregnancy or breastfeedingonly if benefits clearly outweigh poten-tial risks to fetusGOLIMUMAB (Simponi)Available formPrefilled syringe/injector pen: 50 mg/0.5mLAction● IgG1 monoclonal antibody● binds to tumour necrosis factor (TNF),which mediates chronic inflammation● half-life 9–15 daysUse● moderate to severe active rheumatoidarthritis (with methotrexate)● active, progressive psoriatic arthritis(with methotrexate)● active ankylosing spondylitisDose● 50 mg SC monthlyAdverse effects● upper respiratory tract infections, viralinfections, bronchitis, sinusitis, fungalinfection● injection site reaction (erythema,urticaria, induration, pain, pruritus,bruising)● dizziness, paraesthesia, asthenia● rash● hypertension● constipation● elevation liver enzymes● autoantibody formation, increasedrisk of malignancy● allergic reactionInteractions● contraindicated with anakinra orabatacept● not recommended with live attenu-ated vaccinesNursing points/Cautions● patient should be screened for anysigns of infection and/or abscessesbefore starting therapy. This shouldinclude screening for tuberculosis(clinical history, chest X-ray, skin tu-berculin test) and hepatitis B. If latenttuberculosis is diagnosed, it should betreated with appropriate antimycobac-terial agents before starting therapy.Patient should also be asked about re-cent travel or residence in areas wherefungal infections are commonSample chapter
    • 32HAVARD’S NURSING GUIDE TO DRUGS● SC injections should be given onsame date each month● rotate injection sites, avoiding skinthat is reddened, bruised, tender orhard or within 3 cm of previous injec-tion sites● do not administer if solution is disco-loured, cloudy or if foreign particlesare present● long half-life should be taken intoconsideration if patient is undergoingsurgery; post-surgery, patient shouldbe closely monitored for any signs ofinfection (due to increased risk)● patients should be closely monitoredduring and after therapy for any signsof infection for at least 5 months● needle covers of prefilled syringescontain latex and should not be han-dled by or administered to anyonewith a latex sensitivity● protect from light by storing prefilledpen/syringe in outer carton in fridge(2–8° C); do not shake prefilled pen/syringe● patients with active rheumatoid ar-thritis (especially if treated previouslywith immunosuppressant agents) areat increased risk of leukaemia andlymphoma and should be carefullymonitored during and after therapy● therapy is not recommended in thosean active infection● caution if used in those with a historyof malignancy, congestive heart fail-ure, demyelinating diseases, chronicobstructive pulmonary disease orheavy smokers● contraindicated in those with activetuberculosis or severe infection, ormoderate to severe heart failurePatient teaching and advice● instruct patients to seek medicaladvice immediately if they developpersistent fever, bruising, bleeding orpaleness (signs of blood dyscrasias),upset stomach, loss of appetite, vom-iting, tiredness, urine becomes yellowor brown, skin or eyes yellow (signs ofhepatitis B), persistent cough, weightloss, fever or lethargy (signs of tuber-culosis)● patients may be taught to self-administer medication SC. Theyshould be educated about rotationof sites, injection technique (includ-ing not shaking solution), storage re-quirements and safe disposal of usedneedles, as well as what to do if theyforget to administer a dose● needle covers on prefilled syringe andinjector pen contains latex and shouldnot be handled by or administered toanyone with a latex sensitivity● counsel women of childbearing po-tential to use reliable contraceptionduring therapy and for 6 months post-therapy, and also the importance oftelling their doctor if menstruation isdelayed. Breastfeeding should not becommenced within 6 months of stop-ping therapy● see general Patient teaching andadvice (p. xxiii)not recommended during pregnancy orbreastfeeding.HYDROXYCHLOROQUINE SULFATE(Plaquenil)Available formTablets: 200 mgAction● aminoquinoline antimalarial● onset of action: may take 2–6 monthsbefore benefits are apparentUse● rheumatoid arthritis● systemic and discoid lupus erythema-tosus (mild)● treatment and suppression of malaria(see Antimalarial agents)Sample chapter
    • 33ANALGESICS, NSAIDs AND DMADsDose● (lupus erythematosus) initially 400–800 mg orally daily for several weeksreducing to maintenance dose of200–400 mg daily OR● (rheumatoid arthritis) 400–600 mgorally daily with food, increasing doseslowly after 5–10 days until optimaldose is achieved without adverseeffects for 4–12 weeks, reducing toa maintenance dose of 200–400 mgdaily when clinical improvement isestablishedAdverse effects● nausea, abdominal pain, diarrhoea● skin eruptions, alopecia● (rare) corneal/retinal changes, blurredvision, photophobia, halos, retinopa-thy, bone marrow depression, muscleweakness, decreased/absent deeptendon reflexes, anorexia, vomitingInteractions● incompatible with MAOIs● use with digoxin may increase plasmadigoxin levels leading to toxicity● may enhance hypoglycaemic ac-tion of insulin or oral hypoglycaemicagentsNursing points/Cautions● because the effect of hydroxychloro-quine accumulates, maximum clinicaleffects may take several months to beachieved; however, side-effects mayappear much earlier● ophthalmological examination (co-lour vision, fundoscopy, visual fields)should be done before starting ther-apy and continued every 6 monthsduring treatment or more often inthose at high risk (e.g. dose > 6 mg/kg, elderly, kidney/liver impairment,visual problems in previous 8 years).Visual disturbances/retinal changescan continue to occur after therapyhas stopped● patients on long-term therapy shouldhave regular full blood counts andtesting of knee and ankle reflexes tomonitor muscle strength. If any weak-ness occurs, medication should bestopped● if rash appears, the drug should bewithdrawn and recommenced at alower dose● therapy should be stopped if there isno clinical improvement in 6 months● caution if used in those with kidney orliver impairment, quinine sensitivity orG-6-PD deficiency● not recommended in those with por-phyria or psoriasis as symptoms maybecome exacerbated, or in those withsevere GI, neurological or blood dis-orders● contraindicated in those with pre-existing maculopathy● contraindicated in those with hyper-sensitivity to 4-aminoquinolone com-pounds● contraindicated as long term therapyin childrenPatient teaching and advice● patients concurrently taking digoxinshould have digoxin levels monitoredregularly● patient should be advised to reportany visual disturbances (e.g. blurredvision, changes to night vision, lightflashes or streaks) or rash immedi-ately to doctor● warn patients about dangers of driv-ing or operating machinery if blurredvision or impaired coordination occur● patient should be advised to wearsunglasses in strong sunlight● inform patients that clinical effect maytake months to be noticeable, howev-er, adverse effects may occur sooner● if patient has diabetes, he/she shouldbe instructed to monitor blood glu-cose levels closely as etanerceptmay cause hypoglycaemia. Dose ofantidiabetic medications may need tobe adjusted accordinglySample chapter
    • 34HAVARD’S NURSING GUIDE TO DRUGS● see general Patient teaching andadvice (p. xxiii)not recommended during pregnancy un-less benefits outweigh the risks (Note:this is the recommendation for use asan antimalarial) and used with greatcaution during breastfeedingINFLIXIMAB (Remicade)Available formVial: 100 mgAction● IgG1 monoclonal antibody● binds to tumour necrosis factor (TNF),which mediates chronic inflammation● half-life 8–9.5 daysUse● moderate to severe Crohn’s disease(in patients over 6 years) who do notrespond to conventional treatment),moderately severe to severe active ul-cerative colitis, treatment of refractoryfistulising Crohn’s disease (see Gas-trointestinal agents (Miscellaneous))● rheumatoid arthritis (with methotrex-ate)● ankylosing spondylitis● psoriatic arthritis (not responsive toother DMARDs)● severe plaque psoriasis (not respon-sive to other conventional treatment)Dose● (rheumatoid arthritis) initially 3 mg/kgIV over 2 hours, then 3 mg/kg IV givenat 2 and 6 weeks after the first infu-sion, then 3 mg/kg IV 8-weekly (withmethotrexate) OR● (ankylosing spondylitis) 5 mg/kg IVover 2 hours, then 5 mg/kg IV given at2 and 6 weeks after the first infusion,followed by 5 mg/kg IV 6-weekly OR● (psoriatic arthritis, plaque psoriasis)5 mg/kg IV over 2 hours, then 5 mg/kg at 2 and 6 weeks after initial dose,then 8-weekly (maintenance)Adverse effects● infusion-related reaction (dyspnoea,urticaria, hypertension, flushing,headache)● headache, fatigue, fever, dizziness,vertigo● nausea, abdominal pain, diarrhoea,dyspepsia● upper and lower respiratory tract in-fection, dyspnoea, sinusitis, reactiva-tion of tuberculosis (rare)● viral infection● chest pain● rash, pruritus, urticaria, dry skin, in-creased sweating● abnormal liver function● flushing, serum sickness-like reaction● autoantibody development● (long-term) development of malig-nancyInteractions● contraindicated with anakinra (inter-leukin-1 receptor antagonist)● should not be given with live attenu-ated vaccinesNursing points/Cautions● patient should be screened for anysigns of infection and/or abscessesbefore starting therapy. This shouldinclude screening for tuberculosis(clinical history, chest X-ray, skin tu-berculin test). If latent tuberculosis isdiagnosed, it should be treated withappropriate antimycobacterial agentsbefore starting therapy● gently add 10 mL Water for Injec-tion down the inside of the vial, swirlgently and avoid shaking to dissolve.Foaming may occur● allow solution to stand for 5 minutesbefore administering● solution may be colourless to lightyellow and clear● should be diluted to 250 mL with so-dium chloride 0.9%, gently mixed andthen given as an IV infusion (rate notSample chapter
    • 35ANALGESICS, NSAIDs AND DMADsgreater than 2 mL/min) over at least2 hours● a filter (micron size 1.2 or less) shouldbe added to the infusion set● administer alone● patient should be carefully observedfor at least 2 hours post-infusion (es-pecially after the first and seconddose), because infusion reactions aremost likely to occur during this time● if infusion reaction occurs, infusionshould be slowed or stopped untilsymptoms subside, then started at alower rate● paracetamol, antihistamines, corti-costeroids, adrenaline and artificialairway should be readily available forinfusion reaction● premedication with paracetamol,hydrocortisone and/or antihistaminemay prevent mild and transient ef-fects of infusion reaction● re-administration after a 16-weekdrug-free interval is not recommend-ed because of increased risk of hy-persensitivity reaction● caution if given to those with CNSdemyelinating disease or history ofmalignancy● contraindicated in those with severeinfections (including active tuberculo-sis) or congestive heart failurePatient teaching and advice● patient should be advised to imme-diately report any persistent cough,weight loss or low-grade fever● see also general Patient teaching andadvice (p. xxiii)women of childbearing age should beadvised to use adequate contraceptionduring and for 6 months after stoppingtherapynot recommended during breastfeeding,which should also be avoided within6 months of therapyLEFLUNOMIDE (Arabloc, Arava,Lunava)Available formsTablets: 10 mg, 20 mg, 100 mgAction● immunomodulating and immunosup-pressant actions● weak anti-inflammatory properties● converted to active metabolite byfirst-pass metabolism in the gut walland liver● active metabolite has a half-life ofapproximately 2 weeks● clinical improvement may occur in4 weeks, and usually occurs in 4–6monthsUse● active rheumatoid arthritis● active psoriatic arthritisDose● 100 mg orally daily for 3 days (loadingdose), then 10–20 mg daily (mainte-nance)Adverse effects● rash, hair loss (reversible), pruritus,dry skin, hair and skin discolouration● allergic reaction● diarrhoea, abdominal pain, dys-pepsia, nausea, anorexia, vomiting,mouth ulceration, weight loss● elevated liver enzymes● cystitis● hypertension, chest pain● respiratory infection, bronchitis,cough, pharyngitis, sinusitis, rhinitis,pneumonia● dizziness, headache● paraesthesia, asthenia● blurred vision● hypokalaemia● arthralgia, leg cramps, synovitis, te-nosynovitis, tendon rupture● (rare) haematological disorder, hepati-tis, jaundice, severe infection● (very rare) severe skin reactionSample chapter
    • 36HAVARD’S NURSING GUIDE TO DRUGSInteractions● cholestyramine and activated char-coal rapidly decrease plasma levels● may increase plasma levels of rifam-picin and phenytoin● excessive alcohol intake should beavoided● vaccination with live vaccines shouldbe avoided during and for at least 6months after finishing therapy● not recommended with other agentsthat are hepatotoxic or haemotoxic/myelotoxic (e.g. methotrexate). Ifused together, increased monitoringof adverse effects is recommended● caution if given with NSAIDs becauseof increased risk of hepatotoxicityNursing points/Cautions● before starting, every 4 weeks for 6months and then 6–8 weekly duringtherapy patients should have a fullblood count (including differentialwhite cell count), platelet count andliver function tests● patients with previous tuberculosisshould be closely monitored for anyreactivation and should be advised toreport any persistent cough or weightloss immediately● blood pressure should be monitoredbefore starting and throughout ther-apy● treatment should be immediatelyceased if ulcerative stomatitis is evi-dent● because of the long half-life (1–4weeks) of the active metabolite, re-covery from any adverse effects maytake some time● risk of adverse effects when givenwith methotrexate may be lessenedby avoiding giving a loading dose ofmethotrexate● (washout procedure before concep-tion) leflunomide is stopped, thencholestyramine 8 g orally three timesdaily or 50 g orally activated char-coal 4 times daily for 11 days total.Cholestyramine and activated char-coal may both interfere with oralcontraceptives, and therefore barrierforms of contraception should also beused. Plasma levels should be mea-sured twice, 2 weeks apart● contraindicated in those with severeimmunodeficiency states, impairedbone marrow function, blood dyscra-sias, severe uncontrolled infection,liver impairment, severe hypoprotein-aemia or who have (or had) severeskin reactions (e.g. Stevens–Johnsonsyndrome)Patient teaching and advice● patients should be advised to swal-low the tablet whole with water, at thesame time every day● warn patients to avoid excessive al-cohol intake● instruct patient to immediately reportany sore throat, rash, excessive tired-ness or flu-like symptoms● caution patients against driving oroperating machinery if dizziness orblurred vision occur● if female patient is undergoing wash-out procedure prior to conception(see above), advise her to use a bar-rier method of contraception in addi-tion to oral contraceptive, as failuremay occur due to the cholestyramineor activated charcoal● counsel women of childbearing po-tential to use reliable contraceptionduring therapy and the importance oftelling their doctor if menstruation isdelayed● men and women are advised that lev-els of active metabolite should be be-low 0.02 mg/L on two separate teststaken 14 days apart before consider-ing pregnancy after washout proce-dure (above)● see general Patient teaching and ad-vice (p. xxiii)Sample chapter
    • 37ANALGESICS, NSAIDs AND DMADsbefore starting treatment, pregnancymust be excluded and women of child-bearing potential should be advisedto use reliable contraception duringtherapy and must advise their doctor ifmenstruation is delayedvery high risk of causing permanentdamage to the fetus and therefore con-traindicated during pregnancy or breast-feedingMETHOTREXATE (Methaccord,Methoblastin, Methotrexate Injectionand Tablets)Available formsTablets: 2.5 mg, 10 mg; Vials: 5 mg/2 mL,50 mg/2 mL, 100 mg/4 mL, 500 mg/5mL, 500 mg/20 mL, 1000 mg/10 mL,5000 mg/50 mLAction● inhibits metabolism of folic acid,thereby interfering with cell replica-tion (especially in rapidly dividing cellssuch as dermal epithelial cells, buccaland intestinal cells)● decreases swelling, pain and stiffnessin rheumatoid arthritis, but does notinduce remission or affect bone ero-sion● onset of action may take 6–8 weeksUse● antineoplastic agent (see Antineo-plastic agents)● severe psoriasis that is unresponsiveto other treatments● severe rheumatoid arthritis that is un-responsive to other treatmentsDose● (rheumatoid arthritis) 7.5 mg orallyonce weekly (or 2.5 mg orally for 3doses at 12-hourly intervals week-ly). May be increased by 15 mg/week after 6 weeks if no response(weekly maximum 20 mg). Once aresponse is established, dose shouldbe decreased to the lowest that pro-duces a clinical effect OR● (psoriasis) 10–25 mg orally onceweekly, gradually increasing toachieve optimal response but notexceeding 50 mg/week. Once a re-sponse is established, dose shouldbe decreased to the lowest that pro-duces a clinical effect OR● (psoriasis) 2.5 mg orally for 3 dosesat 12-hourly intervals weekly, gradu-ally increasing to achieve optimalresponse, but not exceeding 30 mg/week. Once a response is estab-lished, dose should be decreased tothe lowest that produces a clinicaleffect OR● (psoriasis) 2.5 mg orally daily for 5days, followed by 2-day rest period,gradually increasing to achieve op-timal response, but not exceeding6.25 mg/day. Once a response is es-tablished, dose should be decreasedto the lowest that produces a clinicaleffectAdverse effects● nausea, abdominal pain, diarrhoea,anorexia, vomiting● ulcerative stomatitis, mucositis● decreased serum albumin, acute orchronic liver toxicity● skin reaction, hair loss (reversible),dermatitis, photosensitivity● cystitis, haematuria, dysuria, renalfailure● pneumonitis, pulmonary fibrosis● bone marrow depression● hypotension, pericarditis● malaise, fatigue, chills and fever,headache, dizziness, drowsiness, tin-nitus, blurred vision, eye discomfort,decreased resistance to infection● increased risk of secondary tumourformation, increased risk of infection● (high and prolonged therapy) hepa-totoxicitySample chapter
    • 38HAVARD’S NURSING GUIDE TO DRUGSInteractions● serum levels (and associated risk oftoxicity) may be increased by salicy-lates, sulfonamides, sulfonylureas,phenytoin, penicillins, chlorampheni-col, probenecid and are therefore notrecommended together● (high dose) not recommended withNSAIDs due to increase risk of myelo-suppression and GI toxicity becausehalf-life of methotrexate is prolonged.Caution should also be used with low-er doses of methotrexate● increased risk of soft tissue necrosisand osteonecrosis if given with radio-therapy● toxicity may be increased by folatedeficiency● serum levels may be decreased bycholestyramine● risk of toxicity increased if given withother antineoplastic agents● (antineoplastic agent) not recom-mended with vitamin supplementscontaining folic or folinic acid● contraindicated with acitretin or otherretinoids● contraindicated with alcohol and oth-er hepatotoxic agents (e.g. retinoids,azathioprine, leflunamide)● not recommended with live, attenu-ated vaccines● increased risk of bone marrow de-pression if given with allopurinol,trimethoprim/sulfamethoxazole, pyri-methamine and triamterene● increased risk of myelosuppressionand stomatitis if given with nitrousoxide● (use in psoriasis) increased risk of skinulceration if given with amiodarone● may decrease clearance of theophyl-line, thereby increasing risk of toxicity.Theophylline levels should be closelymonitored during concurrent therapy● may be antagonised by asparaginase● increased risk of toxicity if given withtransfusion of packed red blood cells● incompatible with cytarabine, fluor-ouracil and prednisolone● absorption and metabolism may bedecreased by chloramphenicol, tet-racycline and non-absorbable broadspectrum antibiotics● may increase plasma levels of mer-captopurine● increased risk of pancytopenia if giv-en with leflunomide● increased risk of skin cancer if givenwith PUVA therapyNursing points/Cautions● pregnancy should be excluded beforestarting therapy● adverse effects are generally doserelated● full blood count, haematocrit, renalfunction test, liver function test (in-cluding serum albumin and prothrom-bin time), urinalysis (urine should bealkaline) and chest X-ray should all becompleted before, during (4–8 week-ly) and after therapy. Liver biopsy maybe recommended if patient has his-tory of excessive alcohol use, chronichepatitis B or C infection or persis-tently abnormal liver function test● (psoriasis) liver biopsy is recommend-ed before, during (2–4 monthly), aftera cumulative dose of 1.5 g and thenafter each additional 1–1.5 g● it is important to ensure the patienthas a good understanding of the dos-ing regimen as accidental daily dos-ing (instead of weekly) may be fatal● pregnant staff should be cautionednot to handle methotrexate● tablets contain lactose and are there-fore not recommended in those withgalactose intolerance, Lapp lactasedeficiency or glucose galactose mal-absorption● contraindicated in those with poornutrition, bone marrow depression,blood dyscrasias, liver/renal disor-ders (including alcoholism or alco-holic liver disease), immunodeficiencySample chapter
    • 39ANALGESICS, NSAIDs AND DMADssyndromes, blood dyscrasias, pepticulcer disease, ulcerative colitis, activeor serious infectionPatient teaching and advice● caution patients not to crush or chewtablets, and swallow tablets with afull glass of water. Hands should bewashed immediately after taking tab-lets● warn patients with psoriasis thatburning and redness is common ispsoriatic area for 1–2 days post-therapy● advise patients to maintain goodhydration throughout therapy andimmediately report any vomiting, di-arrhoea or stomatitis that might leadto dehydration● instruct patients to immediately re-port any fever, non-productive cough,chest pain or shortness of breath(dyspnoea) or vomiting, diarrhoeaand/or ulcerative stomatitis● warn patient with rheumatoid arthritisthat it may worsen within 3–6 weeksof therapy being withdrawn● caution patient to avoid excessive sunexposure or sunlamps, as photosen-sitivity reaction may occur, or to weara hat and long-sleeved shirt/garmentand 30+ sunscreen to protect skin ifsun exposure cannot be avoided● it is important to ensure the patienthas a good understanding of the dos-ing regimen as accidental daily dos-ing (instead of weekly) may be fatal● caution patients not to drive or op-erate machinery if dizziness, drowsi-ness, blurred vision or fatigue occur● advise patients that tablets containlactose and are therefore not recom-mended in those with galactose in-tolerance, Lapp lactase deficiency orglucose galactose malabsorption● before treatment begins, all patients(male and female) should be coun-selled regarding potential benefitsand risks of therapy, including effectson reproduction, and the importanceof using effective contraceptionthroughout therapy and for a further3 months after therapy has stopped.Female patients should be instructedto seek medical advice immediatelyif menstruation does not occur andpregnancy is suspected● see also general Patient teaching andadvice (p. xxiii)not recommended during pregnancy be-cause it has been proven to cause fetaldeath and/or congenital abnormalitiesand also severe and/or toxic adverseeffectspregnancy should be excluded beforestarting therapy and should be avoidedfor at least 3 months after withdrawal oftherapy (male and female)contraindicated during breastfeedingPENICILLAMINE (D-Penamine)Available formsTablets: 125 mg, 250 mgAction● exact mode of action in rheuma-toid arthritis is unknown (possiblyinterferes with immune response),although it does chelate metals anddecrease cystine excretion● half-life about 90 hoursUse● chelating agent (see Antidotes, an-tagonists and chelating agents)● management of cysturia● severe active rheumatoid arthritisDose● (rheumatoid arthritis) up to 250mg orally daily in divided doses 1hour before or 2 hours after foodfor 1 month, then increasing by thesame amount monthly to a maximumof 1500 mg daily. The dose is thenSample chapter
    • 40HAVARD’S NURSING GUIDE TO DRUGSlowered to achieve the lowest effec-tive dose (maintenance dose)Adverse effects/Interactions/Nursingpoints/Cautions● if no response occurs in 6 monthsat full maintenance dose, therapyshould be discontinued● contraindicated with current gold salttherapy● contraindicated with antimalarialdrugs● see Adverse effects, Interactions,Nursing points/Cautions for Anti-dotes, antagonists and chelatingagentsPatient teaching and advice● warn patient that it may take 6 to 8weeks for a response to be seen● see general Patient teaching and ad-vice (p. xxiii)SODIUM AUROTHIOMALATE (Gold Salt)(Myocrisin)Available formsAmpoules: 10 mg/0.5 mL, 20 mg/0.5 mL,50 mg/0.5 mLAction● penetrates joint cavity affecting lyso-somal membrane● binds to plasma proteins (includingrheumatoid factor). When ingestedby lysosomes the gold is absorbed,inactivating the enzymesUse● rheumatoid arthritis that is not con-trolled adequately by other DMARDs(adjunctive treatment)● Still’s diseaseDoseRheumatoid arthritis● 1 mg, 5 mg, then 10 mg IM at weeklyintervals to test tolerance, then 50mg/week to a total of 1 g OR● 50 mg/week IM for 20 weeks to a totalof 1 gFor both dosages, continue therapyat 50 mg/month until a total of 3 g hasbeen given (maintenance) or continuedfor 2 years after remissionStill’s disease● under 25 kg: 10 mg● 25–50 kg: 20 mg● over 50 kg: 50 mgGive IM weekly for 6 months. If no im-provement, cease therapy. If responsive,maintenance therapy is continued every2–4 weeks for 1–5 yearsAdverse effects● rash, pruritus (early sign of intoler-ance), erythema, transient eczema● flushing, fainting, dizziness, sweating● proteinuria, haematuria● stomatitis, mouth ulcers● gold deposits on cornea or lens (clearwithin 3–6 months of stopping ther-apy)● (uncommon) anorexia, nausea, vomit-ing, abdominal cramps, diarrhoea● (rare but may be fatal) agranulocy-tosis, thrombocytopenia, aplasticanaemia● (rare) anaphylactoid reactions, periph-eral neuropathy, nephritic syndrome,encephalopathyInteractions● not recommended with penicillamineas risk of rashes and bone marrowdepression is increased● gold may exacerbate aspirin-inducedhepatic dysfunction● increased risk of anaphylactoid reac-tions if given with ACE inhibitorsNursing points/Cautions● before injection, inspect for rashesand test urine for protein (30 mg/100mL or more) and blood; discontinuetreatment if proteinuria/haematuria,eosinophilia or rash is present. Fullblood count (including platelet count)should also be performed before ad-ministrationSample chapter
    • 41ANALGESICS, NSAIDs AND DMADs● patient should be observed for atleast 10 minutes after administrationfor any sign of reaction● shake vial thoroughly while holdinghorizontal before withdrawing thedose● syringe and needle must be dry● warm vial to body temperature (byimmersion in warm water) to facilitatedrawing suspension into syringe● give by deep IM injection, then mas-sage the site; the patient must remainrecumbent for 30 minutes after injec-tion because of the possibility of va-somotor reactions/anaphylactic reac-tion, which can occur after any courseof the therapy● ampoules of gold salts are stored ina cool place, protected from light andnot used if darkened in colour● ophthalmological examination isrecommended if any ocular adverseeffect occurs● severe blood dyscrasias may occurwith little warning● caution if used in those with markedhypertension, compromised cerebralor cardiovascular circulation● contraindicated in those with kidneyor liver disease, diabetes, markedtoxaemia, or history of exfoliativedermatitis or blood dyscrasiaPatient teaching and advice● advise patients to report sore throat,mouth or tongue, mouth ulcers, me-tallic taste, and any bruising or un-usual bleeding or skin reactions to thedoctor as blood test (full blood countincluding platelet count) is requiredimmediately● women of childbearing potentialshould be counselled against becom-ing pregnant during therapy and theimportance of using effective contra-ception during therapy and for up to6 months after finishing therapy, asgold is very slowly excreted and maypersist in the tissues for some time● see also general Patient teaching andadvice (p. xxiii)gold preparations are contradicted dur-ing pregnancy or breastfeedingSULFASALAZINE (Pyralin EN,Salazopyrin, Salazopyrin EN-Tabs)Available formsTablets: 500 mg; Tablets (enteric coated):500 mgAction● broken down in the colon by bacteriato 5-aminosalicylic acid and sulfapyri-dine producing an anti-inflammatoryeffect by its action on prostaglandinsynthesis, leukotrienes and arachi-donic acid metabolites● onset of action may take 6–12 weeksUse● ulcerative colitis and Crohn’s disease(see Gastrointestinal agents (Miscel-laneous agents))● rheumatoid arthritis that is unrespon-sive to other drug therapyDose● (rheumatoid arthritis) initially 500 mgorally at night for 1 week, 500 mgtwice daily for 1 week, 500 mg in themorning and 1 g at night for 1 week,then 1 g twice daily for 1 week (todaily maximum of 3 g)Adverse effects● anorexia, nausea, vomiting, diarrhoea● fever, headache● erythema, pruritus, rash● reversible oligospermia● (rare) hypersensitivity reaction, agran-ulocytosis, aplastic anaemiaInteractions● may potentiate oral anticoagulants,methotrexate and sulfonylureas● reduces absorption and metabolismof folic acid, resulting in folic acidSample chapter
    • 42HAVARD’S NURSING GUIDE TO DRUGSdeficiency, macrocytosis and pancy-topenia● reduces absorption of digoxin, there-fore blood levels should be monitored● increased blood levels may occur inpatients taking oral anticoagulants,indomethacin, sulfinpyrazone, urinaryacidifiers or salicylates● decreased absorption may occur ifgiven with antacids or ferrous sulfate● increased risk of bone marrow de-pression and leucopenia if given withazathioprine● activity may be decreased if givenwith para-aminobenzoic acid-typelocal anaestheticsNursing points/Cautions● enteric-coated tablets are available ifGI intolerance is experienced● monitor blood counts (including dif-ferential white cell count), liver func-tion tests and renal function analysis(including urinalysis) before startingtherapy, second weekly for 3 monthsand then every 3 months● adverse effects are mainly dose de-pendent● encourage adequate fluid intake toreduce risk of crystalluria and stoneformation● caution if given to those with glucose-6-phosphate dehydrogenase defi-ciency (as risk of haemolytic anaemiais increased) or severe allergy, bron-chial asthma or atopic disease● not recommended in those with blooddyscrasia or impaired liver or kidneyfunction● contraindicated in those with any al-lergy/hypersensitivity to sulfonamideor salicylate derivatives, intestinal/urinary obstruction, porphyria orblood dyscrasiasPatient teaching and advice● instruct patients that enteric-coatedtablets should not be crushed or bro-ken but swallowed whole with plentyof water● warn patient to report sore throat,fever, pallor, purpura, jaundice,yellow-orange discolouration of skin,urine and other body fluids to doctorimmediately● instruct patient to drink plenty ofwater during therapy● counsel male patients about revers-ible male infertility and female pa-tients regarding potential harm todeveloping fetus● see also general Patient teaching andadvice (p. xxiii)may inhibit absorption and metabolismof folic acid leading to folic acid defi-ciency, potentially resulting in blooddisorders or harm to developing fetusmay cause reversible male infertilitynot used during breastfeeding unlessthe expected benefit outweighs anypotential riskSample chapter