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2011 nurses drug handbook 2011 nurses drug handbook Document Transcript

  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page iii 2011 Nurse’s Drug Handbook
  • The Drug Reference That Gives You More! Take drug information with you wherever you go! Powered by Skyscape, this software offers instant access to all of the content found in the 2011 Nurse’s Drug Handbook. Accurate index of all generic, trade, and alternate drug names for quick reference with timely facts on hundreds of drugs from abacavir sulfate to Zyvox No-nonsense writing style that speaks your language in terms you use every day Mechanism-of-action illustrations show how drugs work at the cellular, tissue, or organ levels Download it to your mobile device! www.skyscape.com/jbrndrug92381_FMXx_Skyscape_PDI.indd 1 6/21/10 10:54:41 AM
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page v Jones & Bartlett Learning 2011 Nurse’s Drug Handbook Tenth Edition
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page vi World Headquarters Jones & Bartlett Learning Jones & Bartlett Learning Jones & Bartlett Learning 40 Tall Pine Drive Canada International Sudbury, MA 01776 6339 Ormindale Way Barb House, Barb Mews 978-443-5000 Mississauga, Ontario L5V 1J2 London W6 7PA info@jblearning.com Canada United Kingdom www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online book- sellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com. Copyright © 2011 by Jones & Bartlett Learning, LLC ISBN: 978-0-7637-9238-1 All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information stor- age and retrieval system, without written permission from the copyright owner. The authors, editors, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. Production Credits Publisher: Kevin Sullivan Clinical Reviewer: Marlene Ciranowicz- Acquisitions Editor: Amy Sibley Steenburg, RN, MSN, CDE Associate Editor: Patricia Donnelly Composition: Catherine E. Harold Editorial Assistant: Rachel Shuster Interior Illustrations: Rolin Graphics, Inc. Senior Production Editor: Carolyn F. Rogers Cover Design: Kristin E. Parker Senior Marketing Manager: Rebecca Wasley Cover Image: © ajt/ShutterStock, Inc. V. P., Manufacturing and Inventory Printing and Binding: Malloy, Inc. Control: Therese Connell Cover Printing: Malloy, Inc. 6048 Printed in the United States of America 14 13 12 11 10 10 9 8 7 6 5 4 3 2 1
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page vii Contents Advisors, Reviewers, and Clinical Consultants ix How to Use This Book xiv Foreword xix Overview of Pharmacology 1 Principles of Drug Administration 8 Drug Therapy and the Nursing Process 12 Individual Drugs (organized alphabetically) A 17 B 123 C 163 D 281 EF 363 GHI 475 JKL 557 M 613 NO 707 P 785 QRS 885 T 975 UVW 1069 XYZ 1093 Appendices Insulin Preparations 1111 Selected Ophthalmic Drugs 1114 Antihistamines 1124 Selected Topical Drugs 1126 Selected Antivirals 1142 Selected Antineoplastic Drugs 1149 Selected Antihypertensive Combinations 1166 Vitamins 1174 Interferons 1186 Compatible Drugs in a Syringe 1192 Drug Formulas and Calculations 1194 Weights and Equivalents 1199 Equianalgesic Doses for Opioid Agonists 1201 Abbreviations 1202 Index 1205 vii
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page viii
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page ix Advisors Jack E. Fincham, RPh, PhD Ruth Stanley, PharmD, FASHP Dean and Professor of Pharmacy Consultant Practice Birmingham, AL School of Pharmacy University of Kansas Joseph P. Zbilut, RN,C, DNSc, PhD, Lawrence, KS ANP Professor Martha Mitchell Funnell, RN, MS, CDE Adult Health Nursing Associate Director for Administration Rush University College of Nursing Diabetes Research and Training Center Professor University of Michigan Molecular Biophysics and Physiology Ann Arbor, MI Rush Medical College Chicago, IL Mary E. MacCara, PharmD Associate Professor Patti Rager Zuzelo, RN,CS, MSN, EdD College of Pharmacy Associate Professor Assistant Professor School of Nursing Department of Family Medicine La Salle University Dalhousie University Philadelphia, PA Halifax, NS, Canada Associate Director of Nursing for Research S. Edet Ohia, PhD Albert Einstein Medical Center Professor of Pharmaceutical Sciences Philadelphia, PA Associate Dean for Administration Casual Pool Registered Nurse School of Pharmacy and Allied Health Emergency Trauma Care Professions Abington Memorial Hospital Creighton University Abington, PA Omaha, NE Kristine A. Quart, PharmD Medical Education Consultant Olivenhain, CA ix
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page x Reviewers and Clinical Consultants Reviewers Peter J. Ambrose, PharmD Jason M. Cota, PharmD, MS, BCPS Associate Clinical Professor, Step III Assistant Professor, Department of Director Pharmacy Practice Los Angeles-Orange County Area University of the Incarnate Word Clerkships Feik School of Pharmacy University of California, San Francisco Infectious Diseases Clinical Pharmacist San Francisco, CA Brooke Army Medical Center (BAMC) San Antonio, TX Donna Barto, RN, MA, CCRN Nurse Educator Kimberly A. Couch, PharmD Helene Fuld School of Nursing Clinical Pharmacy Specialist, Infectious Blackwood, NJ Diseases Staff Nurse Department of Pharmacy Virtua Memorial Hospital Christiana Care Health System Mount Holly, NJ Newark, DE Edward M. Bednarczyk, PharmD Brenda S. Frymoyer, RN, MSN Clinical Assistant Professor Clinical Nurse Specialist Pharmacy Practice and Nuclear Berks Cardiologists, Inc. Medicine Reading, PA State University of New York at Buffalo Buffalo, NY Kimberly A. Galt, PharmD, FASHP Associate Professor of Pharmacy Cristina E. Bello, PharmD Practice Assistant Professor of Pharmacy Director Practice Drug Information Services College of Pharmacy Co-Director Nova Southeastern University Center for Practice Improvement and Fort Lauderdale, FL Outcomes Research Creighton University Scott M. Bonnema, PharmD Omaha, NE Consultant Pharmacist Emissary Pharmacy and Infusion John Gatto, RPh Casper, WY Clinical Pharmacist Eckerd Pharmacy Felesia R. Bowen, RN, MS, PNP,C Owego, NY Clinical Nurse Specialist Children’s Hospital at Robert Wood Deborah L. Green, RN, MSN Johnson University Hospital Director New Brunswick, NJ Medical Telemetry-CHF Program Moses H. Cone Health System Cynthia Burman, PharmD Greensboro, NC Clinical Assistant Professor School of Pharmacy Ronald L. Greenberg, PharmD, BCPS Temple University Clinical Pharmacy Coordinator Philadelphia, PA Fairview Ridges Hospital Burnsville, MN x
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page xi Jan K. Hastings, PharmD Amista A. Lone, PharmD Assistant Professor Clinical Assistant Professor College of Pharmacy College of Pharmacy University of Arkansas for Medical University of Arizona Science Tucson, AZ Little Rock, AR Jennifer L. Lutz, PharmD Michael D. Hogue, PharmD Pharmacy Resident Assistant Professor of Pharmacy Samuel S. Stratton Veterans Affairs Practice Medical Center McWhorter School of Pharmacy Albany, NY Samford University Clinical Coordinator T. Donald Marsh, PharmD, FASCP, Walgreen Drug Store FASHP Birmingham, AL Director Department of Pharmacotherapy Kimberly A. Hunter, PharmD Mountain Area Health Education Assistant Professor of Pharmacy Center Practice Asheville, NC Albany College of Pharmacy Albany, NY Patrick McDonnell, PharmD Assistant Professor of Clinical William A. Kehoe, Jr., PharmD, BCPS, Pharmacy FCCP School of Pharmacy Professor of Clinical Pharmacy and Temple University Psychology Philadelphia, PA School of Pharmacy and Health Sciences Kenyetta N. Nesbitt, PharmD University of the Pacific Assistant Professor Stockton, CA Wayne State University Detroit, MI Julienne K. Kirk, PharmD, BCPS, CDE Assistant Professor Catherine M. Oliphant, PharmD Department of Family Medicine Assistant Professor of Pharmacy School of Medicine Practice Wake Forest University School of Pharmacy Winston-Salem, NC University of Wyoming Laramie, WY Peter G. Koval, PharmD, BCPS Clinical Pharmacist Michael A. Oszko, PharmD, BCPS Moses H. Cone Family Practice Associate Professor Greensboro, NC Dept. of Pharmacy University of Kansas Lisa M. Krupa, RN,C, CEN, FNP Kansas City, KS Nurse Practitioner Medical Specialists Munster, IN xi
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page xii Reviewers and Clinical Consultants (cont’d) Reviewers (cont’d) Vinita B. Pai, PharmD Melissa L. Sanders, PharmD Assistant Professor of Pharmacy Assistant Professor of Clinical Practice Pharmacy College of Pharmacy School of Pharmacy Idaho State University Temple University Pocatello, ID Philadelphia, PA David J. Quan, PharmD Regina E. Silk, PharmD, RPh, BCPS Clinical Pharmacist Assistant Clinical Professor University of California, San Francisco University of Connecticut Health San Francisco, CA Center Farmington, CT Susan M. Rao, RN, MSN Staff Nurse Elizabeth Sloand, RN, MSN, CPNP Intensive Care Unit Assistant Professor Saint Luke East School of Nursing Fort Thomas, KY Johns Hopkins University Baltimore, MD Susan L. Ravnan, PharmD Assistant Professor of Pharmacy Thomas F. Turco, PharmD Practice Clinical Pharmacist School of Pharmacy and Health Assistant Director of Pharmacy Sciences Our Lady of Lourdes Medical Center University of the Pacific Camden, NJ Stockton, CA Lili Wang, PhD Brenda M. Reap-Thompson, RN, MSN Assistant Professor Nurse Educator School of Pharmacy Community College of Philadelphia Memorial University of Newfoundland Philadelphia, PA St. Johns, NF, Canada Nurse Consultant Chauncey International, ETS Craig Williams, PharmD Princeton, NJ Clinical Specialist Wishard Memorial Hospital Nancy Jex Sabin, RN, MSN, CFNP Assistant Professor of Clinical Instructor Pharmacy Hahn School of Nursing and Health School of Pharmacy Science Purdue University Family Nurse Practitioner Indianapolis, IN Student Health Center University of San Diego San Diego, CA xii
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page xiii Clinical Consultants Madeline Albanese, RN, MSN Pamela S. Ronning, RN, MPA Nurse Educator Program Coordinator Hospital of the University of Kirkhof School of Nursing Pennsylvania Grand Valley State University Philadelphia, PA Allendale, MI Sheree M. Fitzgerald, RN,C, MSN, Maureen Ryan, RN,CS, MSN, FNP CNA Assistant Professor Program Coordinator Grand Valley State University Ancora Psychiatric Hospital Allendale, MI Hammonton, NJ Nurse Practitioner Emergency Dept. Maryann Foley, RN, BSN St. Mary’s Hospital Independent Consultant Grand Rapids, MI Flourtown, PA Julie M. Smith, RN, BA Grace Hukushi, RN, BSN, LNC Staff Nurse Critical Care Nurse Radiology-Heart Station Nursing Enterprises, Inc. Rancocas Hospital Brick, NJ Willingboro, NJ Sammie Justesen, RN, BSN Aaron J. Strehlow, RN,CS, FNP-C, Independent Nurse Consultant NPNP Providence, UT Administrator and Director of Clinical Services Catherine T. Kelly, RN, PhD, CCRN, UCLA School of Nursing CEN, ANP Health Center at the Rescue Mission Faculty Los Angeles, CA School of Nursing Mount Saint Mary College Maria Wilson, RN, MSN, CCRN Newburgh, NY Staff Nurse Emergency Department Sharon Kumm, RN, MN, CCRN Chestnut Hill Hospital Assistant Professor Philadelphia, PA School of Nursing University of Kansas Kansas City, KS Leanne McQuade, RN, BSN, CEN Staff Nurse Emergency Department Doylestown Hospital Case Manager CAB Medical Consultant Doylestown, PA xiii
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page xiv How to Use This Book Jones & Bartlett Learning 2011 Nurse’s organ levels. In addition, the inside Drug Handbook gives you what today’s front cover features a table listing all the nurses and nursing students need: accu- drugs whose mechanisms of action are rate, concise, and reliable drug facts. This illustrated as well as other drugs with book emphasizes the vital information the same mechanisms of action. you need to know before, during, and • No-nonsense writing style speaks after drug administration. The informa- everyday language and uses the terms tion is presented in easy-to-understand and abbreviations you typically language and organized alphabetically, so encounter in your practice and your you can find what you need quickly. studies. To avoid sexist language, we What’s Special alternate between male and female pro- In addition to the drug information you nouns throughout the book. expect to find in each entry (see “Drug • Up-to-date drug information includes Entries” for details), the 2011 Nurse’s the latest FDA-approved drugs, new and Drug Handbook boasts these special fea- changed indications, new warnings, and tures: newly reported adverse reactions. • Dosage adjustment, headlined in color, • A new design makes it easy to find the most need-to-know drug information, alerts you to expected dosage changes such as indications, dosages, dosage for a patient with a specific condition or adjustments, and warnings. disorder, such as advanced age or renal • A new size makes the 2011 Nurse’s Drug impairment. Handbook easier and more convenient • Warning, displayed in color, calls atten- to carry and use. But even though the tion to important facts that you need to book is now smaller and more conven- know before, during, and after drug ient, this new edition contains more administration. For example, in the ala- drug information than ever. We made trofloxacin entry, this feature informs the book smaller and better without you that the drug usually is reserved for taking anything out. hospitalized patients and is given for no • Practical trim size allows the book to more than 2 weeks because of the high open flat so you can find the informa- risk of severe liver damage. tion you need without wrestling with a • Easy-to-use tables showing route, onset, book that wants to close. You can hold peak, and duration (see page xv for the book in one hand, see complete more details) and other tables in the pages at a glance, and use your other appendices provide a timesaving way to hand to document or perform other track and check information. The activities. appendices give you an overview of the • Introductory material reviews essential most important facts and nursing con- general information you need to know siderations for important drug groups, to administer drugs safely and effective- including insulin preparations and ly, including an overview of pharmacol- selected antihistamines, topical drugs, ogy and the principles of drug adminis- antivirals, antineoplastic drugs, interfer- tration. In addition, the five steps of the ons, and antihypertensive combination nursing process are explained and relat- drugs. You’ll also find handy instruc- ed specifically to drug therapy. tions for calculating drug dosages and • Highly useful illustrations throughout I.V. flow rates. the text help you visualize selected Drug Entries mechanisms of action by showing how The 2011 Nurse’s Drug Handbook clearly drugs work at the cellular, tissue, and and concisely presents all the vital facts xiv
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page xv on the drugs that you’ll typically admin- ister. To help you find the information FDA pregnancy risk you need quickly, drug entries are organ- categories ized alphabetically by generic drug Each drug may be placed in a pregnancy name—from abatacept to zonisamide. risk category based on the FDA’s esti- For ease of use, every drug entry follows mate of risk to the fetus. If the FDA has- a consistent format. However, if specific n’t provided a category, the Drug details are unknown or don’t apply, the Handbook notes that the drug is “Not rated.”The categories range from A to X, heading isn’t included so you can go signifying least to greatest fetal risk. right to the next section. GENERIC AND TRADE NAMES A Controlled studies show no risk First, each entry identifies the drug’s Adequate, well-controlled studies with main generic name as well as alternate pregnant women have failed to demon- generic names. (For drugs prescribed by strate a risk to the fetus in any trimester of pregnancy. trade name, you can quickly check the comprehensive index, which refers you to B No evidence of risk in humans the appropriate generic name and page.) Next, the entry lists the most common Adequate, well-controlled studies with pregnant women haven’t shown U.S. trade names for each drug. It also increased risk of fetal abnormalities includes common trade names available despite adverse findings in animals, or, in only in Canada, marked (CAN). the absence of adequate human studies, CLASS, CATEGORY, AND SCHEDULE animal studies show no fetal risk. The chance of fetal harm is remote, but Each entry lists the drug’s chemical and remains possible. therapeutic classes. With this informa- tion, you can compare drugs in the same C Risk can’t be ruled out chemical class but in different therapeu- Adequate, well-controlled human studies tic classes and vice versa. are lacking, and animal studies have The entry also lists the FDA’s pregnan- shown a risk to the fetus or are lacking as cy risk category, which categorizes drugs well. A chance of fetal harm exists if the based on their potential to cause birth drug is given during pregnancy, but the defects. (For details, see FDA pregnancy potential benefits may outweigh the risk. risk categories.) Where appropriate, the entry also D Positive evidence of risk includes the drug’s controlled substance Studies in humans, or investigational or schedule. (For details, see Controlled sub- post-marketing data, have shown fetal risk. Nevertheless, potential benefits from stance schedules, page xvi.) the drug’s use may outweigh risks. For INDICATIONS AND DOSAGES example, the drug may be acceptable if This section lists FDA-approved thera- needed in a life-threatening situation or peutic indications. For each indication, serious disease for which safer drugs can’t be used or are ineffective. you’ll find the applicable drug form or route, age-group (adults, adolescents, or X Contraindicated in pregnancy children), and dosage (which includes Studies in animals or humans, or investi- amount per dose, timing, and duration, gational or post-marketing reports, have when known and appropriate). shown positive evidence of fetal abnor- ROUTE, ONSET, PEAK, AND DURATION malities or risks that clearly outweigh any Quick-reference tables show the drug’s possible benefit to the patient. onset, peak, and duration (when known) xv
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page xvi maximum therapeutic response. The Controlled substance duration of action is the amount of time schedules the drug remains at a blood level that produces a therapeutic response. The Controlled Substances Act of 1970 mandated that certain prescription drugs MECHANISM OF ACTION be categorized in schedules based on This section concisely describes how a their potential for abuse. The greater drug achieves its therapeutic effects at their abuse potential, the greater the cellular, tissue, and organ levels, as appro- restrictions on their prescription. The controlled substance schedules range priate. Illustrations of selected mecha- from I to V, signifying highest to lowest nisms of action lend exceptional clarity abuse potential. to sometimes complex processes. INCOMPATIBILITIES I High potential for abuse In this section, you’ll be alerted to drugs No accepted medical use exists for or solutions that are incompatible with Schedule I drugs, which include heroin and lysergic acid diethylamide (LSD). the topic drug when mixed in a syringe or solution or infused through the same II High potential for abuse I.V. line. Use may lead to severe physical or psy- CONTRAINDICATIONS chological dependence. Prescriptions An alphabetical list details the conditions must be written in ink or typewritten and disorders that preclude administra- and must be signed by the prescriber. Oral prescriptions must be confirmed tion of the topic drug. in writing within 72 hours and may be INTERACTIONS given only in a genuine emergency. No This section includes drugs, foods, and renewals are permitted. activities (such as alcohol use and smok- III Some potential for abuse ing) that can cause important, problem- Use may lead to low-to-moderate phys- atic, or life-threatening interactions with ical dependence or high psychological the topic drug. For each interacting drug, dependence. Prescriptions may be oral food, or activity, you’ll learn the effects of or written. Up to five renewals are per- the interaction. mitted within 6 months. ADVERSE REACTIONS IV Low potential for abuse Organized by body system, this section Use may lead to limited physical or psy- highlights common, serious, and life- chological dependence. Prescriptions threatening adverse reactions. may be oral or written. Up to five NURSING CONSIDERATIONS renewals are allowed within 6 months. Warnings, general precautions, and key V Subject to state and local regulation information that you must know before, Abuse potential is low; a prescription during, and after drug administration are may not be required. detailed in this section. Examples include whether a pill can be crushed and how to properly reconstitute, dilute, store, han- for each administration route. The onset dle, or dispose of a drug. of action is the time a drug takes to be Patient teaching information is also absorbed, reach a therapeutic blood level, included here. You’ll find important and elicit an initial therapeutic response. guidelines for patients, such as how and The peak therapeutic effect occurs when when to take each prescribed drug, how a drug reaches its highest blood concen- to spot and manage adverse reactions, tration and the greatest amount of drug which cautions to observe, when to call reaches the site of action to produce the the prescriber, and more. To save you xvi
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page xvii Teaching your patient about drug therapy Your teaching about drug therapy will vary with your patient’s needs and your practice setting. To help guide your teaching, each drug entry provides key information that you must teach your patient about that drug. For all patients, however, you also should:  Teach the generic and trade name for help him develop a dosing schedule each prescribed drug that he’ll take that prevents these adverse reactions. after discharge—even if he took the  Inform the patient which adverse reac- drug before admission. tions resolve with time.  Clearly explain why each drug was pre-  Teach the patient how to store the drug scribed, how it works, and what it’s sup- properly. Let him know if the drug is posed to do. To help your patient sensitive to light or temperature and understand the drug’s therapeutic how to protect it from these elements. effects, relate its action to her disorder or condition.  Instruct the patient to store the drug in its original container, if possible, with  Review the drug form, dosage, and the drug’s name and dosage clearly route with the patient. Tell him whether printed on the label. the drug is a tablet, suppository, spray, aerosol, or other form, and explain how  Inform the patient which devices to use—and which to avoid—for drug to take it correctly. Also, tell him how storage or administration. For example, often to take the drug and for what warn him not to take liquid cyclo- length of time. Emphasize that he sporine with a plastic cup or utensils. should take the drug exactly as pre- scribed.  Teach the patient what to do if she misses a dose. Generally, she should  Describe the drug’s appearance, and take a once-daily drug as soon as she explain that scored tablets can be bro- remembers—provided that she remem- ken in half for safe, accurate dosing. bers within the first 24 hours. If 24 hours Warn the patient not to break unscored have elapsed, she should take the next tablets because doing so may alter the scheduled dose, but not double the drug dosage. If your patient has trouble dose. If she has questions or concerns swallowing capsules, explain that she about missed doses, tell her to contact can open ones that contain sprinkles the prescriber. and take them with food or a drink but that she shouldn’t do this with capsules  Provide information specific to the pre- that contain powder. Also, warn her not scribed drug. For example, if a patient to crush or chew enteric-coated, takes a diuretic to manage heart failure, extended-release, sustained-release, or instruct him to weigh himself daily at similar drug forms. the same time of day, using the same scale, and wearing the same amount of  Teach the patient about common clothing. Or if the patient takes digoxin adverse reactions that may occur. or an antihypertensive drug, teach him Advise him to notify the prescriber at how to measure his pulse and blood once if a dangerous adverse reaction, pressure and how to record the meas- such as syncope, occurs. urements. Then instruct him to bring  Warn her not to suddenly stop taking a the diary to his regular appointments drug if she’s bothered by unpleasant so the prescriber can monitor his adverse reactions, such as a rash and response to the drug. mild itching. Instead, encourage her to discuss the reactions with her pre-  Advise the patient to refill prescriptions promptly, unless she no longer needs scriber, who may adjust the dosage or the drug. Also instruct her to discard substitute a drug that causes fewer expired drugs because they may adverse reactions. become ineffective or even dangerous  Because drugs may cause adverse reac- over time. tions, such as dizziness and drowsiness, that can impair the patient’s ability to  Warn the patient to keep all drugs out of the reach of children at all times. perform activities that require alertness, xvii
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page xviii time, however, this section doesn’t repeat basic patient-teaching points. (For a Federal guidelines for summary of those, see Teaching your drug disposal patient about drug therapy, page xvii, and Give patients these important instruc- Federal guidelines for drug disposal, page tions for properly disposing of their xviii.) unwanted presciption drugs: In short, Jones & Bartlett Learning  Take unused, unneeded, or outdated 2011 Nurse’s Drug Handbook is designed prescription drugs out of their origi- expressly to give you more of what you nal containers and throw them in the need. It puts vital drug information at trash. your fingertips and helps you stay ALWAYS  Consider mixing discarded prescrip- CURRENT in this critical part of your prac- tion drugs with a substance like cof- tice or studies. fee grounds or used cat litter and putting them in impermeable, non- descript containers, such as empty cans or sealable bags.  Flush prescription drugs down the toilet only if the label or accompany- ing patient information specifically tells you to do so.  See if your community has a phar- maceutical take-back program that allows citizens to bring unused drugs to a central location for proper disposal. xviii
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page xix Foreword Safe, effective drug therapy is one of your technicians to fill them. This forces the most important responsibilities. Not remaining nurses to care for more infrequently, a patient’s life will depend patients. Second, hospital patients are on your ability to give drugs accurately older and more acutely ill, and they typi- and safely. In addition, you must keep up cally receive more complex drug therapy with the latest drug information, includ- than ever. Together, these factors place ing newly approved drugs and recently greater demands on you—increasing reported life-threatening adverse reac- your stress level, reducing the time you tions, as well as those drugs withdrawn have to concentrate on drug administra- from the market after widespread use. tion, and increasing your risk of making Despite all the drug information avail- medication errors or overlooking serious able, medication errors remain one of the adverse reactions or interactions. greatest threats to patients’ well-being The same factors reduce your time and a leading cause of lawsuits against and energy for learning the latest drug nurses, physicians, and hospitals. facts—which you need to have at your Your Responsibilities in Drug Therapy command. You must have this informa- Your basic responsibilities in drug thera- tion at your fingertips because your next py include: patient may need a recently approved • administering the right drug in the right drug or a complex and unfamiliar drug dose by the right route at the right time regimen. to the right patient How can you balance your limited • knowing the therapeutic use, dosage, time, on the one hand, with your need to interactions, adverse reactions, and know the latest developments, on the warnings of each administered drug other? • being aware of newly approved drugs Meeting Your Needs that may be prescribed Nurses and students need a reliable, • knowing about changes to existing accurate, easy-to-use, quick-reference drugs, such as new indications and drug book. They need a book clearly dosages and recently discovered adverse written by and for nurses that has been reactions and interactions reviewed by experts in nursing and phar- • concentrating fully when preparing and macology. You hold such a book in your administering drugs hands: Jones & Bartlett Learning 2011 • responding promptly and appropriately Nurse’s Drug Handbook, with its ALWAYS to serious or life-threatening adverse CURRENT features. reactions, interactions, and complica- The content of 2011 Nurse’s Drug tions Handbook was developed, written, and • instructing each patient about the drug, edited by experienced practicing nurses. how it’s administered, which effects it Expert consultants, reviewers, and advi- causes or may cause, and which reac- sors—both nurses and pharmacists— tions to watch for and report. help ensure the accuracy and reliability of Several factors may reduce your ability the information covered in each entry to meet these basic responsibilities—and and help target that information to your contribute to medication errors. First, needs. What’s more, every drug fact is hospitals and other health care facilities checked against the most prominent drug have budget constraints that may result references today, including the American in the elimination of professional nursing Hospital Formulary Service Drug positions or the hiring of less qualified Information, Drug Facts and Comparisons, xix
  • 92381_FMxx_pi-xx 6/2/10 7:13 PM Page xx The Physicians’ Desk Reference, the FDA’s because you’ll have easy access to accu- website of new drug approvals, and the rate, reliable drug information that’s rel- USP DI’s Drug Information for the Health evant to your practice Care Professional. • stay current on the most up-to-date In addition, to help you quickly access drug developments of the year much-needed information, the book is • improve your drug administration skills organized alphabetically by generic drug and patient care before, during, and name, follows a consistent format, and is after drug therapy concise. • quickly detect and manage serious or To ensure that you’re always current, life-threatening adverse reactions and Jones & Bartlett Learning Nurse’s Drug complications or prevent them from Handbook is updated every year. This occurring newest edition contains: • save time because you won’t have to • important new drug entries in the main sift through volumes of information to part of the book and in the appendices find what you need, search for a book • new drug facts on hundreds of existing that’s up-to-date, or look through sever- entries, including updated information al drug handbooks to get enough infor- on new indications and dosages, new mation incompatibilities and interactions, new • increase your confidence about drug adverse reactions, and new nursing con- administration and enhance your pro- siderations fessional interactions with other health • hundreds of patient-teaching guidelines care team members and suggestions • ensure the delivery of safe, effective care • thoroughly updated appendices on • improve the depth and quality of your insulin preparations, antiviral drugs, patient teaching. topical drugs, antihistamines, combina- Reaping the Rewards tion antihypertensive drugs, interferons, Your patients deserve the best and safest ophthalmic drugs, and antineoplastic care possible—and you deserve to have drugs the tools to deliver that care. Whether • a comprehensive new index. you’re a student or an experienced clini- And as always, you’ll find the same cian, Jones & Bartlett Learning 2011 color-coded, highly readable type that Nurse’s Drug Handbook will help you reduces eyestrain as you speed to the provide safe, effective drug therapy information you need. because of its practical, easy-to-under- Getting More from Your Drug stand, accurate, and reliable information Reference on virtually all the drugs you’re likely to Whether you work in or are preparing to administer. work in acute care, home care, long-term This handbook has aided thousands care, or another health care setting, you’ll of nurses in their patient care. Take it want your own copy of the 2011 Nurse’s with you to the clinical setting, share it Drug Handbook. That’s because this book with your peers, and use it to enhance can help you: your present and future position in the • reduce your risk of medication errors nursing profession. Kathleen Dracup, RN, FNP, DNSc, FAAN Dean and Professor School of Nursing University of California, San Francisco San Francisco, CA xx
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 1 Overview of Pharmacology Understanding the basics of pharmacolo- mechanisms of action. For example, the gy is an essential nursing responsibility. therapeutic class antineoplastics can be Pharmacology is the science that deals further classified as alkylating agents, with the physical and chemical proper- antibiotic antineoplastics, antimetabo- ties, and biochemical and physiologic lites, antimitotics, biological response effects, of drugs. It includes the areas of pharmacokinetics, pharmacodynamics, pharmacotherapeutics, pharmacognosy, How drugs are named and toxicodynamics. A drug’s chemical, generic, trade, and offi- The 2011 Nurse’s Drug Handbook cial names are determined at different phases of the drug development process deals primarily with pharmacokinetics, and serve different functions. For exam- pharmacodynamics, and pharmacothera- ple, the various names of the commonly peutics—the information you need to prescribed anticonvulsant divalproex administer safe and effective drug thera- sodium are: py (discussed below). Pharmacognosy is • Chemical name: Pentanoic acid, the branch of pharmacology that deals 2-propyl-, sodium salt (2:1) or (C16H31O4Na) with the biological, biochemical, and eco- • Generic name: divalproex sodium nomic features of naturally occurring • Trade name: Depakote drugs. Toxicodynamics is the study of the • Official name: Divalproex Sodium harmful effects that excessive amounts of Delayed-Release Tablets, USP a drug produce in the body; in a drug A drug’s chemical name describes its overdose or drug poisoning, large drug atomic and molecular structure. The chemical name of divalproex sodium— doses may saturate or overwhelm normal pentanoic acid, 2-propyl-, sodium salt mechanisms that control absorption, dis- (2:1), or C16H31O4Na (pronounced val- tribution, metabolism, and excretion. proate semisodium)—indicates that the drug is a combination of two valproic Drug Nomenclature acid compounds with a sodium molecule Most drugs are known by several attached to only one side. names—chemical, generic, trade, and Once a drug successfully completes official—each of which serves a specific several clinical trials, it receives a generic function. (See How drugs are named.) name, also known as the nonproprietary However, multiple drug names can also name. The generic name is usually derived from but shorter than the chemi- contribute to medication errors. You may cal name. The United States Adopted find a familiar drug packaged with an Names Council is responsible for select- unfamiliar name if your institution ing generic names, which are intended changes suppliers or if a familiar drug is for unrestricted public use. newly approved in a different dose or for Before submitting the drug for FDA a new indication. approval, the manufacturer creates and registers a trade name (or brand name) Drug Classification when the drug appears ready to be mar- Drugs can be classified in various ways. keted. Trade names are copyrighted and Most pharmacology textbooks group followed by the symbol ® to indicate that they’re registered and that their use drugs by their functional classification, is restricted to the drug manufacturer. such as psychotherapeutics, which is Once the original patent on a drug has based on common characteristics. Drugs expired, any manufacturer may produce can also be classified according to their the drug under its own trade name. therapeutic use, such as antipanic or A drug’s official name is the name antiobsessional drugs. Drugs within a under which it’s listed in the United States Pharmacopoeia (USP) and the certain therapeutic class may be further National Formulary (NF). divided into subgroups based on their
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 2 2 Overview of Parmacology modifiers, antineoplastic enzymes, and large to readily diffuse may rely on active hormonal antineoplastics. diffusion, in which special carriers on molecules, including peptides, amino Pharmacokinetics acids, and glucose, transport the drug Pharmacokinetics is the study of a drug’s through the membranes. However, some actions—or fate—as it passes through molecules with selective membrane carri- the body during absorption, distribution, ers can expel foreign drug molecules; this metabolism, and excretion. is why many drugs can’t cross the blood- ABSORPTION brain barrier. Before a drug can begin working, it must Drug absorption begins at the admin- be transformed from its pharmaceutical istration route. The three main adminis- dosage form to a biologically available tration route categories are enteral, par- (bioavailable) substance that can pass enteral, and transcutaneous. Depending through various biological cell mem- on its nature or chemical makeup, a drug branes to reach its site of action. This may be better absorbed from one site process is known as absorption. A drug’s than from another. absorption rate depends on its route of Enteral Administration administration, its circulation through Enteral administration consists of the the tissue into which it’s administered, oral, nasogastric, and rectal routes. and its solubility—that is, whether it’s Oral: Drugs administered orally are more water-soluble (hydrophilic) or fat- absorbed in the GI tract and then pro- soluble (lipophilic). ceed by the hepatic portal vein to the Although drugs may penetrate cellular liver and into the systemic circulation. membranes either actively or passively, Although generally considered the pre- most drugs do so by passive diffusion, ferred route, oral drug administration moving inertly from an area of higher has a number of disadvantages: concentration to an area of lower con- • The oral route doesn’t always yield suffi- centration. Passive diffusion may occur ciently high blood concentrations to be through water or fat. Passive diffusion effective. through water—aqueous diffusion— • Bioavailability may be less than optimal occurs within large water-filled compart- because of incomplete absorption and ments, such as interstitial spaces, and first-pass elimination (the part of across epithelial membrane tight junc- metabolism that occurs during transit tions and pores in the epithelial lining of through the liver before the drug reach- blood vessels. Aqueous diffusion is driven es the general circulation). by concentration gradients. Drug mole- • Drug absorption may be incomplete if cules that are bound to large plasma pro- the drug is degraded by digestive teins, such as albumin, are too large to enzymes or the acidic pH in the stom- pass through aqueous pores in this way. ach or if it’s excreted from the liver into Passive diffusion through fat—lipid diffu- the bile. sion—plays an important role in drug • Food in the GI tract, gastric emptying metabolism because of the large number time, and intestinal motility may also of lipid barriers that separate the aqueous impede drug absorption. compartments of the body. The tendency Nasogastric: Drugs administered of a drug to move through lipid layers through a nasogastric tube enter the between aqueous compartments often stomach directly and are absorbed in the depends on the pH of the medium—that GI tract. is, the ability of the water-soluble or fat- Rectal: Rectal drugs and suppositories soluble drug to form weak acid or weak also enter the GI tract directly after being base. inserted in the rectum and absorbed Drugs with molecules that are too through the rectal mucosa. After being
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 3 Overview of Pharmacology 3 absorbed into the lower GI tract, rectal allows drug absorption through the skin drugs enter the circulation through the or soft-tissue surface. Drugs may be inferior vena cava, bypassing the liver and inhaled, inserted sublingually, applied thus avoiding first-pass metabolism. topically, or administered by the eyes, Suppositories, however, tend to travel ears, nose, or vagina. upward into the rectum, where veins, Inhalation: Inhaled drugs may be given such as the superior hemorrhoidal vein, as a powder and aerosolized or mixed in lead to the liver. As a result, drug absorp- solution and nebulized directly into the tion by this route is often unreliable and respiratory tract, where they’re absorbed difficult to predict. through the alveoli. Inhaled drugs are usually absorbed quickly because of the Parenteral Administration abundant blood flow in the lungs. Parenteral routes may be used whenever Sublingual: Sublingual drug adminis- enteral routes are contraindicated or tration involves placing a tablet, troche, inadequate. These routes include intra- or lozenge under the tongue. The drug is muscular (I.M.), intravenous (I.V.), sub- absorbed across the epithelial lining of cutaneous (SubQ) and intradermal (I.D.) the mouth, usually quickly. This route administration. Drug absorption is much avoids first-pass metabolism. faster and more predictable after par- Topical: Topical drugs—creams, oint- enteral administration than after enteral ments, lotions, and patches—are placed administration. on the skin and then cross the epidermis I.M.: Drugs administered by the I.M. into the capillary circulation. They may route are injected deep into the muscle, also be absorbed through sweat glands, where they’re absorbed relatively quickly. hair follicles, and other skin structures. The rate of drug absorption depends on Absorption by the skin is enhanced if the the vascularity of the injection site, the drug is in a solution. physiochemical properties of the drug, Ophthalmic: Ophthalmic drugs include and the solution in which the drug is solutions and ointments that are instilled contained. or applied directly to the cornea or con- I.V.: I.V. drug administration involves junctiva as well as small, elliptical disks injecting or infusing the drug directly that are placed directly on the eyeball into the blood circulation, allowing for behind the lower eyelid. The movements rapid distribution throughout the body. of the eyeball promote distribution of This route usually provides the greatest these drugs over the surface of the eye. bioavailability. Although ophthalmic drugs produce a SubQ: Drugs administered by the sub- local effect on the conjunctiva or anterior cutaneous route are injected into the chamber, some preparations may be alveolar connective tissue just below the absorbed systemically and therefore pro- skin and are absorbed by simple diffusion duce systemic effects. from the injection site. The factors that Otic: Drops administered into the affect I.M. absorption also affect subcuta- external auditory canal, otic drugs are neous absorption. Absorption by the sub- used to treat infection or inflammation cutaneous route may be slower than by and to soften and remove ear wax. Otic the I.M. route. solutions exert a local effect and may I.D.: Drugs administered intradermally, result in minimal systemic absorption such as purified protein derivative (PPD), with no adverse effects. are injected into the dermis, from which Nasal: Nasal solutions and suspensions they diffuse slowly into the local micro- are applied directly to the nasal mucosa capillary system. by instillation or inhalation to produce Transcutaneous Administration local effects, such as vasoconstriction to Transcutaneous drug administration reduce nasal congestion. Some nasal
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 4 4 Overview of Pharmacology solutions, such as vasopressin, are admin- metabolism and excretion. Drug metabo- istered by this route specifically to pro- lites—and, in some cases, the active drug duce systemic effects. itself—are eventually excreted from the Vaginal: Vaginal drugs include creams, body, usually through bile, feces, and suppositories, and troches that are insert- urine. The primary organ for drug elimi- ed into the vagina, sometimes using a nation is the kidney. Impaired renal func- special applicator. These drugs are tion may alter drug elimination, thereby absorbed locally to treat such conditions altering the drug’s therapeutic effect. as bacterial and fungal infections. Other excretion routes include evapora- DISTRIBUTION tion through the skin, exhalation from Distribution is the process by which a the lungs, and secretion into saliva and drug is transported by the circulating flu- breast milk. ids to various sites, including its sites of A drug’s elimination half-life is the action. To ensure maximum therapeutic amount of time required for half of the effectiveness, the drug must permeate all drug to be eliminated from the body. The membranes that separate it from its half-life roughly correlates with the intended site of action. Drug distribution drug’s duration of action and is based on is influenced by blood flow, tissue avail- normal renal and hepatic function. ability, and protein binding. Typically, the longer the half-life, the less often the drug has to be given and the METABOLISM longer it remains in the body. Drug metabolism is the enzymatic con- version of a drug’s structure into sub- Pharmacodynamics strate molecules or polar compounds Pharmacodynamics is the study of the that are either less active or inactive and biochemical and physiologic effects of are readily excreted. Drugs can also be drugs and their mechanisms of action. A synthesized to larger molecules. drug’s actions may be structurally specific Metabolism may also convert a drug to a or nonspecific. Structurally specific drugs more toxic compound. Because the pri- combine with cell receptors, such as pro- mary site of drug metabolism is the liver, teins or glycoproteins, to enhance or children, the elderly, and patients with inhibit cellular enzyme actions. Drug impaired hepatic function are at risk for receptors are the cellular components altered therapeutic effects. affected at the site of action. Many drugs Biotransformation is the process of form chemical bonds with drug recep- changing a drug into its active metabo- tors, but a drug can bond with a receptor lite. Compounds that require metabolic only if it has a similar shape—much the biotransformation for activation are same way that a key fits into a lock. known as prodrugs. During phase I of When a drug combines with a receptor, biotransformation, the parent drug is channels are either opened or closed and converted into an inactive or partially cellular biochemical messengers, such as active metabolite. Much of the original cyclic adenosine monophosphate or cal- drug may be eliminated during this cium ions, are activated. Once activated, phase. During phase II, the inactive or cellular functions can be turned either on partially active metabolite binds with or off by these messengers. available substrates, such as acetic acid, Structurally nonspecific drugs, such as glucuronic acid, sulfuric acid, or water, to biological response modifiers, don’t com- form its active metabolite. When bio- bine with cell receptors; rather, they pro- transformation leads to synthesis, larger duce changes within the cell membrane molecules are produced to create a phar- or interior. macologic effect. The mechanisms by which drugs inter- EXCRETION act with the body are not always known. The body eliminates drugs by both Drugs may work by physical action (such
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 5 Overview of Pharmacology 5 as the protective effects of a topical oint- scribed for a certain disease can assist you ment) or chemical reaction (such as an in prioritizing drug administration with antacid’s effect on the gastric mucosa), or other patient care activities. Knowing a by modifying the metabolic activity of drug’s desired and unwanted effects may invading pathogens (such as an antibiot- help you uncover problems not readily ic) or replacing a missing biochemical apparent from the admitting diagnosis. substance (such as insulin). This information may also help you pre- AGONISTS vent such problems as adverse reactions Agonists are drugs that interact with a and drug interactions. receptor to stimulate a response. They A drug’s desired effect is the intended or alter cell physiology by binding to plasma expected clinical response to the drug. membranes or intracellular structures. This is the response you start to evaluate Partial agonists can’t achieve maximal as soon as a drug is given. Dosage adjust- effects even though they may occupy all ments and the continuation of therapy available receptor sites on a cell. Strong often depend on your accurate evaluation agonists can cause maximal effects while and documentation of the patient’s occupying only a small number of recep- response. tor sites on a cell. Weak agonists must An adverse reaction is any noxious and occupy many more receptor sites than unintended response to a drug that strong agonists to produce the same occurs at therapeutic doses used for pro- effect. phylaxis, diagnosis, or therapy. Adverse reactions associated with excessive ANTAGONISTS amounts of a drug are considered drug Antagonists are drugs that attach to a overdoses. Be prepared to follow your receptor but don’t stimulate a response; institution’s policy for reporting adverse instead, they inhibit or block responses drug reactions. that would normally be caused by ago- An idiosyncratic response is a genetically nists. Competitive antagonists bind to determined abnormal or excessive receptor sites that are also compatible response to a drug that occurs in a par- with an agonist, thus preventing the ago- ticular patient. The unusual response nist from binding to the site. Noncom- may indicate that the drug has saturated petitive antagonists bind to receptor sites or overwhelmed mechanisms that nor- that aren’t occupied by an agonist; this mally control absorption, distribution, changes the receptor site so that it’s no metabolism, or excretion, thus altering longer recognized by the agonist. Irrever- the expected response. You may be sible antagonists work in much the same unsure whether a reaction is adverse or way that noncompetitive ones do, except idiosyncratic. Once you report the reac- that they permanently bind with the tion, the pharmacist usually determines receptor. the appropriate course of action. Antagonism plays an important role in An allergic reaction is an adverse drug interactions. When two agonists response that results from previous expo- that cause opposite therapeutic effects, sure to the same drug or to one that’s such as a vasodilator and a vasoconstric- chemically similar to it. The patient’s tor, are combined, the effects cancel each immune system reacts to the drug as if it other out. When two antagonists, such as were a foreign invader and may produce morphine and naloxone, are combined, a mild hypersensitivity reaction, charac- both drugs may become inactive. terized by localized dermatitis, urticaria, Pharmacotherapeutics angioedema, or photosensitivity. Allergic Pharmacotherapeutics is the study of reactions should be reported to the pre- how drugs are used to prevent or treat scriber immediately and the drug should disease. Understanding why a drug is pre- be discontinued. Follow-up care may
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 6 6 Overview of Parmacology include giving drugs, including antihista- pregnancy status, and renal and hepatic mines and corticosteroids, to counteract function—may contribute to the need for the allergic response. dosage adjustments. When you encounter An anaphylactic reaction involves an special considerations such as these, be immediate hypersensitivity response prepared to reassess the prescribed characterized by urticaria, pruritus, and dosage to make sure that it’s safe and angioedema. Left untreated, an anaphy- effective for your patient. lactic reaction can lead to systemic CULTURE AND ETHNICITY involvement, resulting in shock. It’s often Certain drugs are more effective or more associated with life-threatening hypoten- likely to produce adverse effects in partic- sion and respiratory distress. Be prepared ular ethnic groups or races. For example, to assist with emergency life support blacks with hypertension respond better measures, especially if the reaction occurs to thiazide diuretics than do patients of in response to I.V. drugs, which have the other races; on the other hand, blacks fastest rate of absorption. also have an increased risk of developing A drug interaction occurs when one angioedema with angiotensin-converting drug alters the pharmacokinetics of enzyme (ACE) inhibitors. A patient’s reli- another drug—for example, when two or gious or cultural background also may more drugs are given concurrently. Such call for special consideration. For exam- concurrent administration can increase ple, a drug made from porcine products or decrease the therapeutic or adverse may be unacceptable to a Jewish or effects of either drug. Some drug interac- Muslim patient. tions are beneficial. For example, when ELDERLY PATIENTS taken with penicillin, probenecid Because aging produces certain changes decreases the excretion rate of penicillin, in body composition and organ function, resulting in higher blood levels of peni- elderly patients present unique therapeu- cillin. Drug interactions also may occur tic and dosing problems that require spe- when a drug’s metabolism is altered, cial attention. For example, the weight of often owing to the induction of or com- the liver, the number of functioning petition for metabolizing enzymes. For hepatic cells, and hepatic blood flow all example, H2-receptor agonists, which decrease as a person ages, resulting in reduce secretion of the enzyme gastrin, slower drug metabolism. Renal function may alter the breakdown of enteric coat- may also decrease with aging. These ings on other drugs. Drug interactions processes can lead to the accumulation of due to carrier protein competition typi- active drugs and metabolites as well as cally occur when a drug inhibits the kid- increased sensitivity to the effects of neys’ ability to reduce excretion of other some drugs in elderly patients. Because drugs. For example, probenecid is com- they’re also more likely to have multiple pletely reabsorbed by the renal tubules chronic illnesses, many elderly patients and is metabolized very slowly. It com- take multiple prescription drugs each petes with the same carrier protein as day, thus increasing the risk of drug sulfonamides for active tubular secretion interactions. and so decreases the renal excretion of sulfonamides. This particular competi- CHILDREN tion can lead to an increased risk of sul- Because their bodily functions aren’t fully fonamide toxicity. developed, children—particularly those under age 12—may metabolize drugs dif- Special Considerations ferently than adults. In infants, immature Although every drug has a usual dosage renal and hepatic function delay metabo- range, certain factors—such as a patient’s lism and excretion of drugs. As a result, age, weight, culture and ethnicity, gender, pediatric drug dosages are very different
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 7 Overview of Pharmacology 7 from adult dosages. The FDA has provided drug manufac- turers with guidelines that define pedi- atric age categories. Unless the manufac- turer provides a specific age range, use these categories as a guide when adminis- tering drugs: • neonates—birth up to age 1 month • infants—ages 1 month to 2 years • children—ages 2 to 12 • adolescents—ages 12 to 16. PREGNANCY The many physiologic changes that take place in the body during pregnancy may affect a drug’s pharmacokinetics and alter its effectiveness. Additionally, exposure to drugs may pose risks for the developing fetus. Before administering a drug to a pregnant patient, be sure to check its assigned FDA pregnancy risk category and intervene appropriately.
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 8 Principles of Drug Administration Because there are thousands of drugs and tion record or drug profile. Regardless of hundreds of facts about each one, taking which drug distribution system your responsibility for drug administration facility uses, you should read the drug can seem overwhelming. One way that label and compare it to the medication you can enhance your understanding of administration record at least three the principles of drug administration is times: to associate, ask, and predict during the • before removing the drug from the dis- critical thinking process. For example, pensing unit or unit dose cart associate each drug with general informa- • before preparing or measuring the pre- tion you may already know about the scribed dose drug or drug class. Ask yourself why a • before opening a unit dose package (just drug is administered by a certain route before administering the drug to the and why it’s given multiple times patient). throughout the day rather than only RIGHT TIME once. Learn to predict a drug’s actions, Various factors can affect the time that a uses, adverse effects, and possible drug drug is administered, such as the timing interactions based on your knowledge of of meals and other drugs, scheduled the drug’s mechanism of action. As you diagnostic tests, standardized times used apply these principles to drug adminis- by the institution, and factors that may tration, you’ll begin to intuitively know alter the consistency of blood levels and which facts you need to make rational drug absorption. Before administering clinical decisions. any p.r.n. drug, check the patient’s chart Prescriptions for patients in hospitals to ensure that no one else has already and other institutions typically are writ- administered it and that the specified ten by a physician on a form called the time interval has passed. Also, document physician’s order sheet or they’re directly administration of a p.r.n. drug immedi- input into a computerized system with an ately. electronic signature. Drugs are prescribed RIGHT DOSE based not only on their specific mecha- Whenever you’re dispensing an unfamil- nisms of action but also on the patient’s iar drug or in doubt about a dosage, profile, which commonly includes age, check the prescribed dose against the ethnicity, gender, pregnancy status, range specified in a reliable reference. Be smoking and drinking habits, and use of sure to consider any reasons for a dosage other drugs. adjustment that may apply to your par- “Rights” of Drug Administration ticular patient. Also, make sure you’re Always keep in mind the following familiar with the standard abbreviations “rights” of drug administration: the right your institution uses for writing prescrip- drug, right time, right dose, right patient, tions. right route, and right preparation and RIGHT PATIENT administration. Always compare the name of the patient RIGHT DRUG on the medication record with the name Many drugs have similar spellings, differ- on the patient’s identification bracelet. ent concentrations, and several generic When using a unit dose system, compare forms. Before administering any drug, the name on the drug profile with that compare the exact spelling and concen- on the identification bracelet. tration of the prescribed drug that RIGHT ROUTE appears on the label with the information Each drug prescription should specify the contained in the medication administra- administration route. If the administra-
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 9 Principles of Drug Administration 9 tion route is missing from the prescrip- Oral tion, consult the prescriber before giving • Tablets: Tablets, the most commonly the drug. Never substitute one route for used dosage form, come in a variety of another unless you obtain a prescription colors, sizes, and shapes. Some tablets for the change. are specially coated for various purpos- RIGHT PREPARATION AND ADMINISTRATION es. Enteric coatings permit safe passage For drugs that need to be mixed, poured, of a tablet through the stomach, where or measured, be sure to maintain aseptic some drugs may be degraded or may technique. Follow any specific directions produce unwanted effects, to the envi- included by the manufacturer regarding ronment of the intestine. Some coatings diluent type and amount and the use of protect the drug from the destructive filters, if needed. Clearly label any drug influences of moisture, light, or air dur- that you’ve reconstituted with the ing storage; some coatings actually con- patient’s name, the strength or dose, the tain the drug, such as procainamide; still date and time that you prepared the others conceal a bad taste. Coatings are drug, the amount and type of diluent also used to ensure appropriate drug that you used, the expiration date, and release and absorption. Some tablets your initials. shouldn’t be crushed or broken because doing so may alter drug release. Administration Routes • Capsules: Capsules are solid dosage Drugs may be administered by a variety forms in which the drug and other of routes and dosage forms. A particular ingredients are enclosed in a hard or route may be chosen for convenience or soft shell of varying size and shape. to maximize drug concentration at the Drugs typically are released faster from site of action, to minimize drug absorp- capsules than from tablets. tion elsewhere, to prolong drug absorp- • Solutions: Drugs administered in solu- tion, or to avoid first-pass metabolism. tion are absorbed more rapidly than Different dosage forms of the same those administered in solid form; how- drug may have different drug absorption ever, they don’t always produce pre- rates, times of onset, and durations of dictable drug levels in the blood. Some action. For example, nitroglycerin is a drugs in solution should be adminis- coronary vasodilator that may be admin- tered with meals or snacks to minimize istered by the I.V., sublingual, oral, or their irritating effect on the gastric buccal route, or as a topical ointment or mucosa. disk. The I.V., sublingual, and buccal • Suspensions: Suspensions are prepara- forms of nitroglycerin provide a rapid tions consisting of finely divided drugs onset of action, whereas the oral, oint- in a suitable vehicle, usually water. ment, and disk forms have a slower onset Suspensions should be shaken before and a prolonged duration of action. administration to ensure the uniformity Drug administration routes include the of the preparation and administration enteral, parenteral, and transcutaneous of the proper dosage. routes. Nasogastric ENTERAL Drugs administered through a nasogas- The enteral route consists of oral, naso- tric or gastrostomy tube enter the stom- gastric, and rectal administration. Drugs ach directly, bypassing the mouth and administered enterally enter the blood esophagus. They’re usually administered circulation by way of the GI tract. This in liquid form because an intact tablet or route is considered the most natural and capsule could cause an obstruction in a convenient route as well as the safest. As a gastric tube. Sometimes a tablet may be result, most drugs are taken enterally, crushed or a capsule opened for naso- usually to provide systemic effects. grastic administration; however, doing so
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 10 10 Principles of Drug Administration will affect the drug’s release. You may (vastis lateralis), the dorsogluteal muscle need to consult a pharmacist to deter- (gluteus maximus), the upper arm (del- mine which tablets can be crushed or toid), or the ventrogluteal muscle (glu- capsules opened. teus medius). I.M. injections typically provide sustained drug action. This route Rectal is commonly chosen for drugs that irri- Some enteral drugs are administered rec- tate the subcutaneous tissue. The drug tally—as suppositories, solutions, or oint- should be injected as far as possible from ments—to provide either local or sys- major nerves and blood vessels. temic effects. When inserted into the rec- tum, suppositories soften, melt, or dis- Intravenous solve, releasing the drug contained inside In I.V. drug administration, an aqueous them. The rectal route may be preferred solution is injected directly into the for drugs that are destroyed or inactivat- vein—typically of the forearm. Drugs ed by the gastric or intestinal environ- may be administered as a single, small- ment or that irritate the stomach. It also volume injection or as a slow, large-vol- may be indicated when the oral route is ume infusion. Because drugs injected I.V. contraindicated because of vomiting or don’t encounter absorption barriers, this difficulty swallowing. The drawbacks of route produces the most rapid drug rectal administration include inconven- action, making it vital in emergency situ- ience, noncompliance, and incomplete or ations. Except for I.V. fat emulsions used irregular drug absorption. as nutritional supplements, oleaginous preparations aren’t usually administered PARENTERAL by this route because of the risk of fat In parenteral drug administration, a drug embolism. enters the circulatory system through an Subcutaneous injection rather than through GI absorp- tion. This administration route is chosen The subcutaneous route may be used to when rapid drug action is desired; when inject small volumes of medication, usu- the patient is uncooperative, uncon- ally 1 ml or less. Subcutaneous injections scious, or unable to accept medication by typically are given below the skin in the the oral route; or when a drug is ineffec- abdominal area, lateral area of the anteri- tive by other routes. Drugs may be inject- or thigh, posterior surface of the upper ed into the joints, spinal column, arteries, arm, or lateral lumbar area. Injection veins, and muscles. However, the most sites should be rotated to minimize tissue common parenteral routes are the intra- irritation if the patient receives frequent muscular (I.M.), intravenous (I.V.), sub- subcutaneous injections—as, for exam- cutaneous (SubQ), and intradermal ple, in a patient who takes insulin. (I.D.) routes. Drugs administered par- Intradermal enterally may be mixed in either a solu- Common sites for I.D. injection are the tion or a suspension; those mixed in a arm and the back. Because only about solution typically act more rapidly than 0.1 ml may be administered intradermal- those mixed in a suspension. Parenteral ly, this route is rarely used except in diag- administration has several disadvantages: nostic and test procedures, such as The drug can’t be removed or the dosage screening for allergic reactions. reduced once it has been injected, and TRANSCUTANEOUS injections typically are more expensive to In transcutaneous administration, a drug administer than other dosage forms crosses the skin layers from either the because they require strict sterility. outside (dermal) or the inside (mucocu- Intramuscular taneous). This route includes sublingual I.M. injections are administered deep (S.L.), inhalation, ophthalmic, otic, nasal, into the anterolateral aspect of the thigh topical, and vaginal administration.
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 11 Principles of Drug Administration 11 Sublingual sive patch or a disk, are among the latest In S.L. administration, tablets are placed developments in topical drug administra- under the tongue and allowed to dissolve. tion. Because they provide slow drug Nitroglycerin is commonly administered release, these systems are typically used to by this route, which allows rapid drug avoid first-pass metabolism and ensure absorption and action. The S.L. route prolonged duration of action. also avoids first-pass metabolism. Vaginal Inhalation Vaginal troches, suppositories, and Some drugs may be inhaled orally or creams are inserted into the vagina for nasally to produce a local effect on the slow, localized absorption. Body pH that respiratory tract or a systemic effect. differs from blood pH causes drug trap- Although drugs given by inhalation avoid ping or reabsorption, which delays drug first-pass hepatic metabolism, the lungs excretion through the renal tubules. can also serve as an area of first-pass Vaginal secretions are alkaline, with a pH metabolism by providing respiratory of 3.4 to 4.2, whereas blood has a pH of conversion to more water-soluble com- 7.35 to 7.45. pounds. Ophthalmic Ophthalmic solutions and ointments are applied directly to the cornea or con- junctiva for enhanced local penetration and decreased systemic absorption. These drugs usually are used in eye examina- tions and to treat glaucoma. Ophthalmic solutions pose a greater risk of drug loss through the nasolacrimal duct into the nasopharynx than ophthalmic ointments do. Otic Otic solutions are instilled directly into the external auditory canal for local pen- etration and decreased systemic absorp- tion. These drugs, which include anes- thetics, antibiotics, and anti-inflammato- ry drugs, usually require occlusion of the ear canal with cotton after instillation. Nasal Nasal solutions and suspensions are applied directly to the nasal mucosa for enhanced local penetration and decreased systemic absorption. These drugs are usually used to reduce the inflammation typically associated with seasonal or perennial rhinitis. Topical Topical drugs—including creams, oint- ments, lotions, and pastes—are applied directly to the skin. Transdermal delivery systems, usually in the form of an adhe-
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 12 Drug Therapy and the Nursing Process A systematic approach to nursing care, history from other sources, such as family the nursing process helps guide you as members, friends, other caregivers, and you develop, implement, and evaluate the medical record. your care and ensures that you’ll deliver PRESENT DRUG USE safe, consistent, and effective drug thera- py to your patients. The nursing process Ask about the patient’s current use of consists of five steps, including assess- over-the-counter and prescription drugs ment, nursing diagnosis, planning, as well as herbal remedies. As you did in implementation, and evaluation. Even the drug history, find out the specific though documentation is not a step in details for each drug (dosage, route, fre- the nursing process, you’re legally and quency, and reason for taking). Also ask professionally responsible for document- the patient if he thinks the drug has been ing all aspects of your care before, dur- effective and when he took the last dose. ing, and after drug administration. If the patient uses herbal remedies, similarly explore the use of these prod- Assessment ucts because herbs may interact with cer- The first step in the nursing process, tain drugs. Also ask about the patient’s assessment involves gathering informa- use of recreational drugs, such as alcohol tion that’s essential to guide your and tobacco, as well as illegal drugs, such patient’s drug therapy. This information as marijuana and heroin. If the patient includes the patient’s drug history, pres- acknowledges use of these drugs, be alert ent drug use, allergies, medical history, for possible drug interactions. This infor- and physical examination findings. mation also may provide you with insight Assessment is an ongoing process that about the patient’s response—or lack of serves as a baseline against which to com- response—to his current drug treatment pare any changes in your patient’s condi- plan. tion; it’s also the basis for developing and Try to find out if the patient has any individualizing your patient’s plan of other problems that might affect his care. compliance with the drug treatment plan, DRUG HISTORY and intervene appropriately. For instance, The patient’s drug history is critical in a patient who is unemployed and has no your planning of drug-related care. Ask health insurance may fail to fill a needed about his previous use of over-the-count- prescription. In such a case, contact an er and prescription drugs as well as appropriate individual in your facility herbal remedies. For each drug, deter- who may be able to help the patient mine: obtain financial assistance. • the reason the patient took it Be sure to ask the patient if his drug • the prescribed dosage treatment plan requires special monitor- • the administration route ing or follow-up laboratory tests. For • the frequency of administration example, patients who take antihyperten- • the duration of the drug therapy sives need to have their blood pressure • any adverse reactions the patient may checked routinely, and those who take have experienced and how he handled warfarin must have their prothrombin them. time tested regularly. Other patients must Also determine if the patient has a his- undergo periodic blood tests to assess tory of drug abuse or addiction. their hepatic and renal function. Depending on his physical and emotional Determine whether the patient has com- state, you may need to obtain the drug plied with this part of his treatment plan,
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 13 Drug Therapy and the Nursing Process 13 and ask him if he knows the results of the milk. If your patient is or might be preg- latest monitoring or laboratory tests. nant, check the FDA’s pregnancy risk cat- ALLERGIES egory for the prescribed drug and notify Find out if the patient is allergic to any the prescriber if the drug may pose a risk drugs or foods. If he has an allergy, to the fetus. If the patient is breast-feed- explore it further by determining the ing, find out if the drug is distributed in type of drug or food that triggers a reac- breast milk and intervene appropriately. tion, the first time he experienced a reac- PHYSICAL EXAMINATION FINDINGS tion, the characteristics of the reaction, As part of the physical examination, note and other related information. Keep in the patient’s age and weight. Be aware mind that some patients consider annoy- that age determines the dosage of certain ing symptoms, such as indigestion, an drugs, such as sedatives and hypnotics, allergic reaction. However, be sure to whereas weight determines the dosage of document a true allergy according to others, including some I.V. antibiotics your facility’s policy to ensure that the and anticoagulants. As you perform the patient doesn’t receive that drug or any physical examination, note any abnormal related drug that may cause a similar findings that may point to body organ or reaction. Also, document allergies to system dysfunction. For example, if you foods because they may lead to drug detect liver enlargement and ascites, the interactions or adverse drug reactions. patient may have impaired hepatic func- For example, sulfite is a food additive as tion, which can affect the metabolism of well as a drug additive, so a patient with a a drug he’s taking and lead to harmful known allergy to sulfite-containing foods adverse or toxic effects. Also note is likely to react to sulfite-containing whether a body organ or system appears drugs. to be responding to drug treatment. For MEDICAL HISTORY example, if a patient has been taking an While reviewing your patient’s medical antibiotic to treat chronic bronchitis, history, determine if he has any acute or thoroughly evaluate his respiratory status chronic conditions that may interfere to measure his progress. And be sure to with his drug therapy. Certain disorders assess the patient for possible adverse involving major body systems, such as reactions to the drugs he’s taking. the cardiovascular, GI, hepatic, and renal Assess the patient’s neurologic function systems, may affect a drug’s absorption, to make sure that he can understand his transport, metabolism, or excretion and drug regimen and carry out required interfere with its action; they also may tasks, such as performing a fingerstick to increase the incidence of adverse reac- obtain blood for glucose measurement. If tions and lead to toxicity. For each disor- the patient can’t understand essential der identified, try to determine when the drug information, you’ll need to identify condition was diagnosed, what drugs a family member or another person who were prescribed, and who prescribed is willing to become involved in the them. This information can help you teaching process. determine whether the patient is receiv- Nursing Diagnosis ing incompatible drugs and whether Based on information derived from the more than one prescriber is managing his assessment and physical examination drug therapy. findings, the nursing diagnoses are state- Ask a female patient if she is or may be ments of actual or potential problems pregnant or if she’s breast-feeding. Many that a nurse is licensed to treat or manage drugs are safe to use during pregnancy, alone or in collaboration with other but others may harm the fetus. Also, members of the health care team. They’re some drugs are distributed into breast worded according to guidelines estab-
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 14 14 Drug Therapy and the Nursing Process lished by the North American Nursing patient, not the nurse, to achieve and Diagnosis Association (NANDA). should include a time frame for measur- One of the most common nursing ing the patient’s progress. An example of diagnoses related to drug therapy is a typical expected outcome is, The patient knowledge deficit, which indicates that the will accurately demonstrate self-adminis- patient doesn’t have sufficient under- tration of insulin before discharge. Based standing of his drug regimen. However, on each outcome statement you establish, adverse reactions are the basis for most you’d then develop appropriate nursing nursing diagnoses related to drug admin- interventions, which might include drug istration. For example, a patient receiving administration techniques, patient teach- an opioid analgesic might have a nursing ing, monitoring of vital signs, calculation diagnosis of constipation related to of drug dosages based on weight, and decreased intestinal motility or ineffective recording of intake and output. breathing pattern related to respiratory Implementation depression. A patient receiving long- As you implement the nursing interven- term, high-dose corticosteroids may have tions, be sure to stringently follow the a risk for impaired skin integrity related to classic rule of drug administration: cortisone acetate or self-concept distur- administer the right dose of the right bance related to physical changes from drug by the right route to the right prednisone therapy. Many antiarrhyth- patient at the right time. Also, keep in mics cause orthostatic hypotension and mind that you have a legal and profes- thus may place an elderly patient at high sional responsibility to follow institution- risk for injury related to possible syncope. al policy regarding standing orders, pre- Broad-spectrum antibiotics, especially scription renewal, and the use of nursing penicillin, may lead to the overgrowth of judgment. During the implementation Clostridium difficile, a bacterium that phase, you’ll also begin to evaluate the normally is present in the intestine. This patient’s expected outcomes and nursing overgrowth in turn may lead to interventions and make necessary pseudomembranous colitis, characterized changes to the plan of care. by abdominal pain and severe diarrhea. The nursing diagnoses in such a case Evaluation might include potential for infection relat- Evaluation is an ongoing process rather ed to bacterial overgrowth, alteration in than a single step in the nursing process. comfort related to abdominal pain, and During this phase, you evaluate each fluid balance deficit related to diarrhea. expected outcome to determine whether or not it has been achieved and whether Planning the original plan of care is working or During the planning phase, you’ll estab- needs to be modified. In evaluating a lish expected outcomes—or goals—for patient’s drug treatment plan, you should the patient and then develop specific determine whether or not the drug is nursing interventions to achieve them. controlling the signs and symptoms for Expected outcomes are observable or which it was prescribed. You also should measurable goals that should occur as a evaluate the patient for psychological or result of nursing interventions and some- physiologic responses to the drug, espe- times in conjunction with medical inter- cially adverse reactions. This constant ventions. Developed in collaboration monitoring allows you to make appropri- with the patient, the outcomes should be ate and timely suggestions for changes to realistic and objective and should clearly the plan of care, such as dosage adjust- communicate the direction of the plan of ments or changes in delivery routes, until care to other nurses. They should be each expected outcome has been written as behaviors or responses for the achieved.
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 15 Drug Therapy and the Nursing Process 15 Documentation You’re responsible for documenting all your actions related to the patient’s drug therapy, from the assessment phase to evaluation. Each time you administer a drug, document the drug name, dose, time given, and your evaluation of its effect. When you administer drugs that require additional nursing judgment, such as those prescribed on an as-needed basis, document the rationale for admin- istering the drug and follow-up assess- ment or interventions for each dose administered. If you decide to withhold a prescribed drug based on your nursing judgment, document your action and the rationale for it, and notify the prescriber of your action in a timely manner. Whenever you notify a prescriber about a significant finding related to drug therapy, such as an adverse reaction, document the date and time, the person you contacted, what you discussed, and how you intervened.
  • 92381_OVER_p0001-0016 6/1/10 10:42 PM Page 16
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 17 abatacept 17 75 kg. Initial: 10 mg/kg infused over A 30 min, repeated in 2 to 4 wk. Maintenance: 10 mg/kg infused over 30 min every 4 wk starting at wk 8. Mechanism of Action A abatacept Inhibits T-cell activation by binding to CD80 and CD86 to block interaction with Orencia CD28. CD28 is part of the co-stimulatory signal needed for full activation of T cells. Class and Category Activated T cells have been implicated in Chemical class: Soluble fusion protein, the pathogenesis of rheumatoid arthritis. human recombinant fusion protein With decreased proliferation of T cells, Therapeutic class: Antirheumatic inflammation and other evidence of Pregnancy category: C rheumatoid arthritis decrease. Indications and Dosages Incompatiblities  To reduce signs and symptoms, induce Don’t infuse abatacept solution with other major clinical response, inhibit progres- drugs in the same intravenous line concur- sion of structural damage, and improve rently because it isn’t known if the drugs physical function in patients with mod- may interact. erate to severe active rheumatoid arthri- Contraindications tis and an inadequate response to Hypersensitivity to abatacept or its compo- methotrexate or a tumor necrosis factor nents antagonist I.V. INFUSION Interactions Adults weighing more than 100 kg DRUGS (220 lb). Initial: 1,000 mg infused over immunosuppressants: Possibly increased risk 30 min, repeated in 2 to 4 wk. Maintenance: of serious infection 1,000 mg infused over 30 min every 4 wk live-virus vaccines: Possibly decreased starting at wk 8. response to vaccine, and risk of infection Adults weighing 60 to 100 kg (132 to with live virus 220 lb). Initial: 750 mg infused over tumor necrosis factor antagonists: Increased 30 min, repeated in 2 to 4 wk. Maintenance: risk of serious infection 750 mg infused over 30 min every 4 wk Adverse Reactions starting at wk 8. CNS: Dizziness, fever, headache Adults weighing less than 60 kg. Initial: CV: Hypertension, hypotension 500 mg infused over 30 min, repeated in 2 EENT: Nasopharyngitis, rhinitis, sinusitis to 4 wk. Maintenance: 500 mg infused over GI: Abdominal pain, diarrhea, diverticulitis, 30 min every 4 wk starting at wk 8.  To reduce signs and symptoms of moder- dyspepsia, nausea GU: Acute pyelonephritis, UTI ate to severe active polyarticular juvenile MS: Back or limb pain idiopathic arthritis RESP: Bronchitis, COPD worsening, cough, I.V. INFUSION dyspnea, pneumonia, upper respiratory Children ages 6 to 17 weighing more than tract infection, wheezing 100 kg. Initial: 1,000 mg infused over SKIN: Cellulitis, flushing, pruritus, rash, 30 min, repeated in 2 to 4 wk. Maintenance: urticaria 1,000 mg infused over 30 min every 4 wk Other: Anaphylaxis, antibody formation, starting at wk 8. herpes simplex, herpes zoster infection, Children ages 6 to 17 weighing 75 to influenza, malignancies, varicella infection 100 kg. Initial: 750 mg infused over 30 min, repeated in 2 to 4 wk. Maintenance: 750 mg Nursing Considerations infused over 30 min every 4 wk starting at • Screen patient for latent tuberculosis with wk 8. a tuberculin skin test before starting abat- Children ages 6 to 17 weighing less than acept. If test is positive, expect to provide
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 18 18 abciximab treatment, as ordered, before starting abat- • Monitor patient closely for evidence of acept. Also screen patient for hepatitis B. If infection or malignancy because abatacept present, expect abatacept to be withdrawn inhibits T-cell activation, increasing the because anti-rheumatic therapies such as risk of these disorders. abatacept may reactivate hepatitis B. PATIENT TEACHING • Review patient’s immunization record, • Instruct patient not to receive immuniza- and make sure all immunizations are cur- tions with live vaccines during abatacept rent before therapy starts. Drug may blunt therapy and for 3 months afterward. effectiveness of some vaccines and increase • Stress need to report any evidence of the risk of infection with live viruses. infection or hypersensitivity to prescriber. • Use cautiously in patients with a history of • Alert patient that abatacept may increase recurrent infections, underlying condi- the risk of maligancy. tions that may predispose them to infec- • Warn patient to avoid crowds and people tion, or existing chronic, latent, or local- with infections. ized infection. They have an increased risk of infection with abatacept therapy. • Use cautiously in patients with COPD and abciximab monitor respiratory status closely because abatacept may worsen COPD and increase ReoPro the risk of adverse respiratory reactions. • Tumor necrosis factor antagonists should- Class and Category n’t be given with abatacept because of an Chemical class: Fab fragment of chimeric increased of serious infection. 7E3 antibody • Reconsititue each vial with 10 ml of sterile Therapeutic class: Platelet aggregation water for injection. Use only the silicone- inhibitor free disposable syringe provided with each Pregnancy category: C vial because a siliconized syringe may Indications and Dosages cause translucent particles to form in solu-  To prevent acute myocardial ischemic tion. After injecting sterile water into vial, complications after percutaneous trans- gently swirl vial until contents are com- luminal coronary angioplasty (PTCA) pletely dissolved. To minimize foaming, in patients at high risk for abrupt clo- don’t shake. Vent the vial with a needle to sure of treated coronary artery dissipate any foam that may be present. I.V. INFUSION OR INJECTION • Further dilute reconstituted solution with Adults. 250-mcg/kg bolus 10 to 60 min 0.9% sodium chloride injection to achieve before PTCA. Maintenance: 0.125 mcg/kg/ a final solution of 100 ml. Slowly add min by continuous infusion for 12 hr. solution into infusion bag or bottle using Maximum: 10 mcg/min. the same silicone-free disposable syringe  To treat unstable angina in patients who provided with each vial. Mix gently. Do haven’t responded to conventional thera- not shake the bag or bottle. py and are scheduled for PTCA within • Give entire dose of fully diluted drug over 24 hr 30 minutes using an infusion set and a I.V. INFUSION OR INJECTION sterile, nonpyrogenic, low protein-binding Adults. 250-mcg/kg by bolus; then 10 mcg/ filter with a pore size of 0.2 µm. min by continuous infusion over 18 to • Once fully diluted, solution may be kept 24 hr, concluding 1 hr after PTCA. for 24 hours at room temperature or refrigerated. If reconstituted solution isn’t Route Onset Peak Duration used within 24 hours, discard. I.V. Unknown Unknown 48 hr • After giving abatacept, monitor patient closely for evidence of hypersensitivity Mechanism of Action reaction such as rash, pruritus, urticaria, Binds to glycoprotein IIb/IIIa receptor sites dyspnea, or wheezing. If present, stop drug on the surface of activated platelets. immediately, notify prescriber, and pro- Circulating fibrinogen can bind to these vide emergency care, as ordered. receptor sites and link platelets together,
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 19 acamprosate calcium 19 forming a clot that eventually blocks a 4.5 ml from 2-mg/ml solution and inject coronary artery. By binding to receptor prescribed amount into 250-ml bag of sites, abciximab prevents normal binding of normal saline solution or D5W using an A fibrinogen and other factors and inhibits in-line sterile, nonpyrogenic, low–protein- platelet aggregation. binding 0.2- to 0.22-micron filter. Discard unused portion. Incompatibilities • Give I.V. bolus with sterile, nonpyrogenic, Don’t mix abciximab with other drugs. Give low–protein-binding 0.2- to 0.22-micron through separate I.V. line when possible. filter. Contraindications • Avoid I.M. injections, venipunctures, and Active internal bleeding, arteriovenous mal- use of indwelling urinary catheters, NG formation or aneurysm, bleeding disorders, tubes, and automatic blood pressure cuffs stroke in past 2 years or that caused signifi- during therapy to prevent bleeding. If cant neurologic deficit at any time, GI or appropriate, insert an intermittent I.V. GU bleeding in past 6 weeks, hypersensitiv- access device to obtain blood samples. ity to abciximab, intracranial neoplasm, I.V. • Watch for GI, GU, and retroperitoneal dextran use before or during PTCA, oral bleeding and bleeding at puncture sites. anticoagulant therapy in past 7 days unless WARNING If hemorrhage occurs, prepare to PT is less than 1.2 times control, severe stop infusion immediately. Expect to treat uncontrolled hypertension, surgery in past severe thrombocytopenia with platelet 6 weeks, thrombocytopenia, vasculitis transfusions if needed. • Monitor patient for hypersensitivity reac- Interactions tions, such as rash, pruritus, wheezing, and DRUGS dysphagia from laryngeal edema. If such dipyridamole, heparin, NSAIDs, oral antico- reactions occur, stop infusion and notify agulants, thrombolytic drugs, ticlopidine: prescriber immediately. If anaphylaxis Increased risk of bleeding occurs, give epinephrine, antihistamines, Adverse Reactions and corticosteroids, as prescribed. CNS: Confusion, dizziness, hyperesthesia • Obtain platelet count 2 to 4 hours after CV: Atrial fibrillation or flutter, bradycar- initial bolus and every 24 hours during dia, embolism, hypotension, peripheral therapy as ordered. Expect platelet func- edema, pseudoaneurysm, supraventricular tion to return to normal within 48 hours tachycardia, third-degree AV block, throm- after therapy ends. bophlebitis, weak pulse • Monitor vital signs and continuous ECG GI: Dysphagia, hematemesis, nausea, vomit- tracings during treatment. ing PATIENT TEACHING GU: Dysuria, hematuria, renal dysfunction, • Teach about possible adverse reactions, urinary frequency, urinary incontinence, including bleeding and hypersensitivity urine retention reactions, which may cause rash, urticaria, HEME: Anemia, bleeding, leukocytosis, and dyspnea. thrombocytopenia • Tell patient to prevent injury from falls by RESP: Bronchitis, bronchospasm, crackles, maintaining bed rest and from bleeding by dyspnea, pleural effusion, pneumonia, pul- keeping limb immobile while catheter monary edema, pulmonary embolism, sheath is in place. wheezing SKIN: Pruritus, rash, urticaria Other: Development of human anti- acamprosate chimeric antibodies calcium Nursing Considerations • Know that abciximab may be used with Campral heparin and aspirin therapy. • Inspect abciximab for particles; don’t use Class and Category if opaque particles are present. Chemical class: Synthetic endogenous • For continuous I.V. infusion, withdraw amino acid homotaurine, gamma-
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 20 20 acamprosate calcium aminobutyric acid (GABA) analogue DOSAGE ADJUSTMENT For patients with Therapeutic class: Antialcoholic moderate renal impairment (creatinine Pregnancy category: C clearance of 30 to 50 ml/min), 333 mg t.i.d. Indications and Dosages  To maintain abstinence from alcohol for Route Onset Peak Duration alcohol-dependent patients who are P.O. Unknown 3–8 hr Unknown abstinent at the start of treatment E.R. TABLETS Contraindications Adults. 666 mg t.i.d. Hypersensitivity to acamprosate or its com- Mechanism of Action Chronic alcoholism may alter the balance ride ion channel and releases chloride between excitation and inhibition in neu- (Cl-) into the cell (below left), thereby rons in the brain; acamprosate restores it. reducing neuronal excitability by inhibit- When the neurotransmitter gamma- ing depolarization. By interacting with aminobutyric acid (GABA) binds to its GABA receptor sites, acamprosate pre- receptors in the CNS, it opens the chlo- vents GABA from binding (below right). Cell exterior Cell exterior Cell exterior Cell exterior GABA GABA GABA GABA GABA GABA GABA GABA Acamprosate Acamprosate Acamprosate Acamprosate Cell exterior Cell exterior Cell exterior Cell exterior Cl – – Cl GABA GABA GABA GABA Receptor Receptor Receptor Receptor GABA GABA GABA GABA Cl – – Cl Acamprosate Acamprosate Rece Receptor Acamprosate Acamprosate Receptor Rece Rece Receptor Receptor Rece Cl – – ptor Cl ptor ptor ptor Receptor Receptor Receptor Receptor Cl – – Cl Rece Receptor Rece ptor Rece Rece Rece ptor Receptor Rece Cell membrane Cell membrane Cell membrane Cell membrane Cl – – Cl Cl – – Cl Cl – – Cl ptor Cl – – ptor ptor Cl ptor Cell interior Cell interior Cell interior Cell interior When glutamatemembrane its receptors, it Cell binds to Cell membrane ance fosters aCell membranealcohol. By craving for Cell membrane Cl – – Cl Cl – – Cl Cl – – Cl closes–the chloride ion channel, increas- Cl – Cell exterior Cell exterior interacting with glutamate receptor sites, Cell exterior Cell exterior Cl Cell interior Cell interior Cell interior Cell interior ing neuronal excitability by promoting Glutamate Glutamate acamprosate prevents glutamate from Glutamate Glutamate depolarization (below left). This imbal- Glutamate Glutamate binding (below right). Acamprosate Acamprosate Glutamate Glutamate Acamprosate Acamprosate Cl – – Cl Cl – – Cl Cell exterior Cell exterior Cell exterior Cell exterior Cl – – Cl Glutamate Glutamate Glutamate Glutamate Glutamate Glutamate Receptor Receptor Acamprosate Acamprosate Receptor Receptor Glutamate Glutamate Cl – – Cl Acamprosate Acamprosate Rece Receptor Receptor Rece Receptor Rece Cl – – Rece Receptor Cl – – Cl Cl Cl – – Cl ptor ptor ptor ptor Receptor Receptor Receptor Cl – – Receptor Cl Rece Receptor Rece ptor Rece ptor Rece Rece Cell membrane Cell membrane Rece Receptor Cell membrane Cell membrane Cl – – Cl Cl – – Cl Cl – – Cl Cl – – Cl ptor ptor ptor Cell interior Cell interior Cell interior Cell interior ptor Cell membrane Cell membrane Cell membrane Cell membrane Cl – – Cl Cl – – Cl Cl – – Cl Cl – – Cl Cell interior Cell interior Cell interior Cell interior
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 21 acarbose 21 ponents, severe hepatic (Child-Pugh class taking acamprosate; the drug may need to C) or renal impairment be stopped because fetal risks are unknown. A Interactions DRUGS antidepressants: Increased weight gain tetracyclines: Decreased absorption of tetra- acarbose cyclines Precose Adverse Reactions CNS: Abnormal thinking, amnesia, anxiety, Class and Category asthenia, chills, depression, dizziness, Chemical class: Alpha-glucosidase inhibitor, headache, insomnia, paresthesia, somno- oligosaccharide lence, suicidal ideation, syncope, tremor Therapeutic class: Antidiabetic drug CV: Chest pain, hypertension, palpitations, Pregnancy category: B peripheral edema, vasodilation EENT: Abnormal vision, dry mouth, Indications and Dosages pharyngitis, rhinitis, taste perversion  To control blood glucose level in patients GI: Abdominal pain, anorexia, constipation, with type 2 (non–insulin-dependent) diarrhea, flatulence, increased appetite, diabetes mellitus when the level can’t be indigestion, nausea, vomiting controlled by diet alone GU: Acute renal failure, decreased libido, TABLETS impotence Adults. Initial: 25 mg t.i.d. with first bite of HEME: Leukopenia, lymphocytosis, throm- each meal. Maintenance: Increased to maxi- bocytopenia mum at 4- to 8-wk intervals p.r.n. MS: Arthralgia, back pain, myalgia Maximum: 50 mg t.i.d. for patients weigh- RESP: Bronchitis, cough, dyspnea ing 65 kg (143 lb) or less; 100 mg t.i.d. for SKIN: Diaphoresis, pruritus, rash patients weighing more than 65 kg. Other: Flulike symptoms, infection, weight Mechanism of Action gain Inhibits action of alpha-amylase and alpha- Nursing Considerations glucoside enzymes. Normally, alpha- • Acamprosate should start as soon as possi- amylase hydrolyzes complex starches to ble after patient has undergone alcohol oligosaccharides in the small intestine and withdrawal and achieved abstinence. alpha-glucoside hydrolyzes oligosaccha- • Continue to give acamprosate even during rides, trisaccharides, and di-saccharides to periods of alcohol relapse. glucose and other monosaccharides in the PATIENT TEACHING brush border of the small intestine. In dia- • Instruct patient to take acamprosate exact- betic patients, acarbose inhibits these ly as prescribed, even if a relapse occurs, actions and delays glucose absorption, and to seek help for a relapse. reducing blood glucose level after meals. • Warn patient that acamprosate won’t Contraindications reduce symptoms of alcohol withdrawal if Chronic intestinal disease, cirrhosis, colonic relapse occurs followed by cessation. ulceration, conditions that may deteriorate • Urge caregivers to monitor patient for evi- because of increased gas formation in intes- dence of depression (lack of appetite or tines, diabetic ketoacidosis, digestive or interest in life, fatigue, excessive sleeping, absorption disorders, history of bowel difficulty concentrating) or suicidal ten- obstruction, hypersensitivity to acarbose, dencies because a small number of inflammatory bowel disease patients taking acamprosate have attempt- ed suicide. Interactions • Advise patient to use caution when per- DRUGS forming hazardous activities until adverse calcium channel blockers, digestive enzymes CNS effects of drug are known. (such as pancreatin), diuretics, estrogen, • Tell female patient to notify prescriber if intestinal adsorbents (such as activated char- she is or intends to become pregnant while coal), isoniazid, nicotinic acid, oral contra-
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 22 22 acebutolol hydrochloride ceptives, phenothiazines, phenytoin, sympa- ing OTC drugs during acarbose therapy. thomimetics, thyroid hormones: Possibly • Advise patient who also takes another decreased therapeutic effects of acarbose antidiabetic to carry glucose with him at digoxin: Decreased serum level and thera- all times in case hypoglycemia occurs. peutic effects of digoxin insulin, sulfonylureas: Decreased insulin action, possibly increased risk of hypo- acebutolol glycemia hydrochloride Adverse Reactions Monitan (CAN), Sectral CV: Edema GI: Abdominal distention and pain, diar- rhea, flatulence, hepatitis, hepatotoxicity, Class and Category ileus, jaundice Chemical class: Beta1-selective (cardioselec- SKIN: Erythema, exanthema, rash, urticaria tive) adrenergic receptor blocker Therapeutic class: Antihypertensive, class II Nursing Considerations antiarrhythmic WARNING Be aware that acarbose isn’t rec- Pregnancy category: B ommended for patients with significant renal dysfunction and a serum creatinine Indications and Dosages  To treat hypertension level above 2 mg/dl. TABLETS • If patient is receiving acarbose and a sulfo- nylurea or insulin to enhance glucose con- Adults. Initial: 400 mg daily or 200 mg trol, check blood glucose level often, as b.i.d. Usual: 200 to 800 mg daily. Increased appropriate. to 1,200 mg daily in divided doses b.i.d. for • Store drug in sealed container in cool severe hypertension or hypertension that environment. isn’t well controlled with usual dosage.  To treat premature ventricular arrhyth- • Expect to decrease dosage to control GI upset. mias TABLETS • Monitor glycosylated hemoglobin level as ordered every 3 months for first year to Adults. Initial: 200 mg b.i.d. Usual: 600 to evaluate glucose control and patient com- 1,200 mg daily. DOSAGE ADJUSTMENT Maximum of 800 mg pliance. • Monitor hematocrit and serum AST level daily for elderly patients. Dosage reduced every 3 months during first year of thera- by 50% for patients with creatinine clear- py and periodically thereafter, as ordered, ance less than 50 ml/min/1.73 m2. Dosage because acarbose may decrease hematocrit reduced by 75% for patients with creatinine and increase serum AST level. clearance less than 25 ml/min/1.73 m2. PATIENT TEACHING • Explain importance of self-monitoring Route Onset Peak Duration glucose level during acarbose therapy. P.O. 1–1.5 hr 2–8 hr 24 hr or • Teach patient to recognize hypoglycemia longer and hyperglycemia. • Warn patient that noncompliance with Mechanism of Action treatment can increase risk of diabetic Inhibits stimulation of beta1 receptors in complications, including neuropathy, the heart, decreasing cardiac excitability, retinopathy, and renal insufficiency. heart rate, cardiac output, and myocardial • Explain that temporary insulin therapy oxygen demand. Acebutolol also decreases may be needed if fever, trauma, infection, kidneys’ release of renin, which helps illness, surgery, or other stress alters blood reduce blood pressure. Drug suppresses SA glucose control. node automaticity and AV node conductivi- • Warn patient not to take other drugs with- ty, which suppresses atrial and ventricular in 2 hours of acarbose unless specifically ectopy. By decreasing myocardial oxygen instructed by prescriber. demand, acebutolol decreases myocardial • Tell him to consult prescriber before tak- ischemia. At high doses, it inhibits stimula-
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 23 acetaminophen 23 tion of beta2 receptors in the lungs and may renal function tests, as ordered. cause bronchoconstriction. • Check apical and radial pulses before giv- ing acebutolol. Also, frequently monitor A Contraindications blood pressure and pulse rate, rhythm, Cardiogenic shock, heart failure unless and quality during treatment. from tachyarrhythmia, hypersensitivity to • Give drug with food to prevent GI upset. acebutolol, overt heart failure, second- and • Acebutolol may elevate uric acid, potassi- third-degree heart block, severe bradycardia um, triglyceride, lipoprotein, and antinu- Interactions clear antibody levels; it also may interfere DRUGS with accuracy of glucose tolerance tests. alpha agonists, nasal decongestants: • Monitor diabetic patient’s blood glucose Increased risk of hypertension level to spot alterations. aluminum salts, barbiturates, calcium salts, • Notify prescriber if you detect a heart rate cholestyramine, colestipol, indomethacin, below 50 beats/min or signs of heart fail- NSAIDs, penicillins, rifampin, salicylates, ure, such as dyspnea, crackles, unexplained sulfinpyrazone: Decreased antihypertensive weight gain, and jugular vein distention. effects • Monitor patient for peripheral edema, and anticholinergics, hydralazine, methyldopa, evaluate fluid intake and output. prazosin, reserpine: Increased risk of brady- PATIENT TEACHING cardia and hypotension • Tell patient that tablets may be crushed or beta2 agonists, theophylline: Decreased bron- swallowed whole. chodilation • Warn against stopping acebutolol abruptly epinephrine: Increased risk of blocked sym- because doing so could cause angina or pathomimetic effects dangerously high blood pressure. ergot alkaloids: Increased risk of peripheral • Instruct patient to take a missed dose as ischemia and gangrene soon as possible up to 6 hours before next flecainide: Possibly increased effects of both scheduled dose but not to double the next drugs dose. lidocaine: Possibly increased serum lido- • Advise patient to consult prescriber before caine level, causing toxicity taking OTC drugs that contain alpha ago- oral contraceptives, quinidine: Possibly nists, such as nasal decongestants and cold increased serum acebutolol level preparations. sulfonylureas: Possibly decreased hypoglyce- • Instruct patient to report dizziness, confu- mic effects sion, and fever immediately. verapamil: Increased cardiac effects, leading • Urge patient to maintain diet and lifestyle to bradycardia and hypotension changes to help control blood pressure. Adverse Reactions CNS: Abnormal dreams, anxiety, confusion, depression, dizziness, fatigue, fever, head- acetaminophen ache, insomnia Abenol (CAN), Acephen, Aceta Elixir, CV: Bradycardia, chest pain, edema, heart Acetaminophen Uniserts, Aceta Tablets, block, heart failure, hypotension Apacet Capsules, Apacet Elixir, Apacet EENT: Abnormal vision, conjunctivitis, dry Extra Strength Tablets, Apacet Regular eyes, eye pain, pharyngitis, rhinitis Strength Tablets, Aspirin Free Pain GI: Constipation, diarrhea, flatulence, Relief, Exdol (CAN), Feverall, Feverall hepatotoxicity, indigestion, nausea Sprinkle Caps, Genapap Infants’ Drops, GU: Dysuria, impotence, polyuria Genebs Extra Strength, Halenol MS: Arthralgia, myalgia Children’s Junior Strength, Liquiprin RESP: Bronchospasm, cough, dyspnea, Elixir, Liquiprin Infants’ Drops, Meda wheezing Cap, Neopap, Oraphen-PD, Panadol, SKIN: Rash Panadol Infants’ Drops, Pediaphen, Nursing Considerations Redutemp, Robigesic (CAN), St. Joseph • Before therapy begins, obtain baseline Aspirin-Free Infant Drops, Tapanol
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 24 24 acetaminophen Extra Strength, Tempra, Tempra Drops, Mechanism of Action Inhibits the enzyme cyclooxygenase, block- Tylenol, Tylenol Caplets, Tylenol ing prostaglandin production and interfer- Children’s Chewable Tablets, Tylenol ing with pain impulse generation in the Extra Strength, Tylenol Gelcaps, peripheral nervous system. Acetaminophen Tylenol Infants’ Drops also acts directly on temperature-regulating center in the hypothalamus by inhibiting Class and Category synthesis of prostaglandin E2. Chemical class: Nonsalicylate, para- aminophenol derivative Therapeutic class: Antipyretic, nonopioid Route Onset Peak Duration analgesic P.O., P.R. Varies 1–3 hr 3–4 hr Pregnancy category: B Contraindications Indications and Dosages Hypersensitivity to acetaminophen or its  To relieve mild to moderate pain from components headache, muscle ache, backache, minor arthritis, common cold, toothache, or Interactions menstrual cramps; to reduce fever DRUGS CAPLETS, CAPSULES, CHEWABLE TABLETS, ELIXIR, anticholinergics: Decreased onset of aceta- E.R. CAPLETS, GELCAPS, LIQUID, SOLUTION, minophen action SPRINKLES, SUSPENSION, TABLETS barbiturates, carbamazepine, hydantoins, iso- Adults. 325 to 650 mg every 4 to 6 hr, or niazid, rifampin, sulfinpyrazone: Decreased 1,000 mg t.i.d. or q.i.d., or 2 E.R. caplets therapeutic effects and increased hepatotox- every 8 hr. Maximum: 4,000 mg daily. ic effects of acetaminophen Children over age 14. 650 mg every 4 hr. lamotrigine, loop diuretics: Possibly Maximum: 5 doses in 24 hr. decreased therapeutic effects of these drugs Children ages 12 to 14. 640 mg every 4 hr. oral contraceptives: Decreased effectiveness Maximum: 5 doses in 24 hr. of acetaminophen Children age 11. 480 mg every 4 hr. probenecid: Possibly increased therapeutic Maximum: 5 doses in 24 hr. effects of acetaminophen Children ages 9 to 10. 400 mg every 4 hr. propranolol: Possibly increased action of Maximum: 5 doses in 24 hr. acetaminophen Children ages 6 to 8. 320 mg every 4 hr. zidovudine: Possibly decreased zidovudine Maximum: 5 doses in 24 hr. effects Children ages 4 to 5. 240 mg every 4 hr. ACTIVITIES Maximum: 5 doses in 24 hr. alcohol use: Increased risk of hepatotoxicity Children ages 2 to 3. 160 mg every 4 hr. Adverse Reactions Maximum: 5 doses in 24 hr. GI: Abdominal pain, hepatotoxicity, nausea, Children age 1. 120 mg every 4 hr. vomiting Maximum: 5 doses in 24 hr. HEME: Hemolytic anemia (with long-term Children ages 4 to 11 months. 80 mg every use), leukopenia, neutropenia, pancytope- 4 hr. Maximum: 5 doses in 24 hr. nia, thrombocytopenia Children ages 0 to 3 months. 40 mg every SKIN: Jaundice, rash, urticaria 4 hr. Maximum: 5 doses in 24 hr. Other: Angioedema, hypoglycemic coma SUPPOSITORIES Adults and adolescents. 650 mg every 4 to Nursing Considerations 6 hr. Maximum: 4,000 mg daily. • Before and during long-term therapy, Children ages 6 to 12. 325 mg every 4 to 6 monitor liver function test results, includ- hr. Maximum: 2,600 mg daily. ing AST, ALT, bilirubin, and creatinine lev- Children ages 3 to 6. 120 to 125 mg every els, as ordered. 4 to 6 hr. Maximum: 720 mg daily. • Monitor renal function in patient on long- Children ages 1 to 3. 80 mg every 4 hr. term therapy. Keep in mind that blood or Children ages 3 months to 11 months. albumin in urine may indicate nephritis; 80 mg every 6 hr. decreased urine output may indicate renal
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 25 acetazolamide 25 failure; and dark brown urine may indi- acute congestive (closed-angle) glaucoma cate presence of the metabolite S.R. CAPSULES, TABLETS, I.V. OR I.M. INJECTION A phenacetin. Adults. 250 mg b.i.d. or every 4 hr; or 1 • Expect to reduce dosage for patients with S.R. capsule (500 mg) b.i.d.; or 500 mg ini- renal dysfunction. tially, followed by 125 to 250 mg every 4 to • Store suppositories under 80° F (26.6° C). 6 hr for severe acute glaucoma. To initially WARNING Be aware that Pediaphen is a con- lower intraocular pressure rapidly, 500 mg centrated form of acetaminophen contain- I.V.; may repeat in 2 to 4 hr in acute cases, ing 80 mg/0.8 ml (standard liquid forms depending on patient response. Oral thera- contain 32 mg/ml). Make sure to use cor- py usually started after initial I.V. dose. rect concentration and dosage of liquid S.R. CAPSULES, TABLETS acetaminophen because serious adverse Children. 10 to 15 mg/kg daily in divided reactions can result from confusing con- doses every 6 to 8 hr. centrated form with regular liquid form. I.V. OR I.M. INJECTION PATIENT TEACHING Children. 5 to 10 mg/kg/dose every 6 hr. • Tell patient that tablets may be crushed or  To induce diuresis in heart failure swallowed whole. TABLETS, I.V. OR I.M. INJECTION • Instruct patient to read manufacturer’s Adults. Initial: 250 to 375 mg or 5 mg/kg label and follow dosage guidelines precise- daily in morning. Maintenance: 250 to ly. Explain that infants’ and children’s acet- 375 mg or 5 mg/kg on alternate days or for aminophen liquid aren’t equal in drug 2 days followed by a drug-free day. concentration and aren’t interchangeable.  To treat drug-induced edema • Advise patient to use manufacturer’s drop- TABLETS, I.V. OR I.M. INJECTION per or dosage cup for measuring liquid Adults. 250 to 375 mg daily for 1 to 2 days. acetaminophen. TABLETS, I.V. INJECTION • Advise him to contact prescriber before Children. 5 mg/kg/dose daily in morning. taking other prescription or OTC products  To treat seizures, including generalized because they may contain acetaminophen. tonic-clonic, absence, and mixed • Teach patient to recognize signs of hepato- seizures, and myoclonic jerk patterns toxicity, such as bleeding, easy bruising, TABLETS, I.V. OR I.M. INJECTION and malaise, which commonly occurs with Adults and children. 8 to 30 mg/kg daily in chronic overdose. divided doses. Optimal: 375 to 1,000 mg daily. When used with other anticonvul- sants, 250 mg daily. acetazolamide  To prevent or relieve symptoms of acute mountain sickness Acetazolam (CAN), Ak-Zol, Apo- S.R. CAPSULES, TABLETS Acetazolamide (CAN), Dazamide, Adults. 500 to 1,000 mg daily in divided Diamox, Diamox Sequels, doses, given 24 to 48 hr before ascent and Storzolamide continued for 48 hr or longer while at high altitude p.r.n. to control symptoms. Class and Category Chemical class: Sulfonamide derivative Route Onset Peak Duration Therapeutic class: Anticonvulsant, anti- P.O. 1–1.5 hr 2–4 hr 8–12 hr glaucoma, diuretic P.O. (S.R.) 2 hr 8–12 hr 18–24 hr Pregnancy category: C I.V. 2 min 15 min 4–5 hr Indications and Dosages  To treat chronic simple (open-angle) Mechanism of Action glaucoma Inhibits the enyzme carbonic anhydrase, S.R. CAPSULES, TABLETS, I.V. OR I.M. INJECTION which normally appears in the eyes’ ciliary Adults. 250 to 1,000 mg daily (divided for processes, brain’s choroid plexes, and kid- doses exceeding 250 mg). neys’ proximal tubule cells. In the eyes,  As short-term therapy to treat secondary enzyme inhibition decreases aqueous glaucoma and preoperatively to treat humor secretion, which lowers intraocular
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 26 26 acetohexamide pressure. In the brain, inhibition may delay Other: Acidosis, hyperuricemia, hypo- abnormal, intermittent, and excessive dis- kalemia, weight loss charge from neurons that cause seizures. In the kidneys, it increases bicarbonate excre- Nursing Considerations tion, which carries out water, potassium, • Use acetazolamide cautiously in patients and sodium, thus inducing diuresis and with calcium-based renal calculi, diabetes metabolic acidosis. This acidosis counter- mellitus, gout, or respiratory impairment. acts respiratory alkalosis and reduces symp- • Know that acetazolamide may increase toms of mountain sickness, including risk of hepatic encephalopathy in patients headache, dizziness, nausea, and dyspnea. with hepatic cirrhosis. • To avoid painful I.M. injections (caused by Contraindications alkaline solution), give acetazolamide by Chronic noncongestive closed-angle glau- mouth or I.V. injection if possible. coma; cirrhosis; hyperchloremic acidosis; • Reconstitute each 500-mg vial with at least hypersensitivity to acetazolamide; 5 ml sterile water for injection. Use within hypokalemia; hyponatremia; severe pul- 24 hours because drug has no preservative. monary obstruction; severe renal, hepatic, • Monitor blood tests during acetazolamide or adrenocortical impairment therapy to detect electrolyte imbalances. Interactions • Monitor fluid intake and output every DRUGS 8 hours and body weight daily to detect amphetamines, methenamine, phenobarbital, excessive fluid and weight loss. procainamide, quinidine: Decreased excre- PATIENT TEACHING tion and possibly toxicity of these drugs • Inform patient that acetazolamide tablets corticosteroids: Increased risk of may be crushed and suspended in choco- hypokalemia late or another sweet syrup. Or, one tablet cyclosporine: Increased cyclosporine level, may be dissolved in 10 ml hot water and possibly nephrotoxicity or neurotoxicity added to 10 ml honey or syrup. diflunisal: Possibly significantly decreased • Advise patient to avoid hazardous activi- intraocular pressure ties if dizziness or drowsiness occurs. lithium: Increased excretion and decreased • Instruct patient who takes high doses of effectiveness of lithium salicylates to notify prescriber immediately primidone: Decreased serum and urine about evidence of salicylate toxicity, such primidone levels as anorexia, tachypnea, and lethargy. salicylates: Increased risk of salicylate toxi- • If patient plans to mountain climb, urge city her to descend mountain gradually and to seek immediate medical care if symptoms Adverse Reactions of mountain sickness occur. CNS: Ataxia, confusion, depression, dis- orientation, dizziness, drowsiness, fatigue, fever, flaccid paralysis, headache, lassitude, malaise, nervousness, paresthesia, seizures, acetohexamide tremor, weakness Dimelor (CAN), Dymelor EENT: Altered taste, tinnitus, transient myopia Class and Category GI: Anorexia, constipation, diarrhea, hepatic Chemical class: Sulfonylurea dysfunction, melena, nausea, vomiting Therapeutic class: Antidiabetic GU: Crystalluria, decreased libido, glyco- Pregnancy category: C suria, hematuria, impotence, nephrotoxici- ty, phosphaturia, polyuria, renal calculi, Indications and Dosages renal colic, urinary frequency  To treat stable type 2 (non–insulin- HEME: Agranulocytosis, hemolytic anemia, dependent) diabetes mellitus leukopenia, pancytopenia, thrombocytope- TABLETS nia, thrombocytopenic purpura Adults. Initial: 250 to 1,500 mg daily. SKIN: Photosensitivity, pruritus, rash, Dosages of 1,000 mg or more daily may be Stevens-Johnson syndrome, urticaria divided and given b.i.d. before morning and
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 27 acetohexamide 27 evening meals. digitalis level DOSAGE ADJUSTMENT For patient being switched from another antidiabetic, aceto- Adverse Reactions A hexamide dosage reduced to half the usual CNS: Anxiety, chills, confusion, depression, tolbutamide dosage or twice the usual dizziness, drowsiness, fatigue, headache, chlorpropamide dosage. For patient being hyperesthesia, insomnia, malaise, nervous- switched from insulin to acetohexamide ness, paresthesia, somnolence, syncope, monotherapy, dosages adjusted as follows: tremor, vertigo, weakness if insulin dosage is less than 20 units daily, CV: Arrhythmias, edema, hypertension, acetohexamide starts at 250 mg daily and vasculitis insulin is discontinued; if insulin dosage EENT: Blurred vision, conjunctivitis, eye exceeds 20 units daily, acetohexamide starts pain, pharyngitis, retinal hemorrhage, at 250 mg daily and insulin is tapered by rhinitis, tinnitus 25% to 30% before being reduced further ENDO: Hypoglycemia according to patient response. GI: Abdominal pain, anorexia, constipation, diarrhea, epigastric fullness, flatulence, heartburn, hepatitis, hepatotoxicity, indi- Route Onset Peak Duration gestion, nausea, proctocolitis, vomiting P.O. 1 hr Unknown 12–24 hr GU: Decreased libido, dysuria, polyuria HEME: Agranulocytosis, aplastic anemia, Mechanism of Action eosinophilia, hemolytic anemia, leukopenia, Stimulates insulin release from active beta pancytopenia, thrombocytopenia cells in the pancreas, resulting in decreased MS: Abnormal gait, arthralgia, hypertonia, blood glucose level. Improves insulin bind- leg cramps ing to insulin receptors. Increases the num- RESP: Dyspnea ber of insulin receptors (with long-term SKIN: Diaphoresis, eczema, erythema mul- administration). May reduce basal hepatic tiforme, exfoliative dermatitis, flushing, glucose secretion. jaundice, lichenoid reaction (skin thicken- Contraindications ing, accentuated lesions), maculopapular Diabetes mellitus complicated by ketoaci- rash, photosensitivity, pruritus, rash, dosis or pregnancy, hypersensitivity to urticaria aceto-hexamide, renal failure, sole therapy Other: Disulfiram-like reaction (flushing, for type 1 (insulin-dependent) diabetes head throbbing, hypotension, nausea, mellitus tachycardia, vomiting), hyponatremia Interactions Nursing Considerations DRUGS • Use acetohexamide cautiously in elderly activated charcoal: Possibly reduced absorp- patients and in those with cardiac, hepatic, tion and effectiveness of acetohexamide or renal disease or thyroid dysfunction. androgens, anticoagulants, azole antifungals, Drug’s duration of action is prolonged in chloramphenicol, clofibrate, fluconazole, gem- patients with renal disease. fibrozil, H2-receptor antagonists, magnesium • Give acetohexamide 30 minutes before salts, MAO inhibitors, methyldopa, meals, crushing tablets if desired. If GI probenecid, salicylates, sulfinpyrazone, sul- upset occurs, give in divided doses, as pre- fonamides, tricyclic antidepressants, urinary scribed. acidifiers: Enhanced hypoglycemic effect of • Watch for evidence of hypoglycemia and acetohexamide hyperglycemia, especially after meals. beta blockers, calcium channel blockers, • Check blood glucose level often, as ordered. cholestyramine, corticosteroids, diazoxide, Provide additional insulin if needed dur- estrogens, hydantoins, isoniazid, nicotinic ing stressful periods, as prescribed. acid, oral contraceptives, phenothiazines, • Monitor liver enzyme levels during thera- rifampin, sympathomimetics, thiazide diuret- py; acetohexamide may increase AST, ALT, ics, thyroid drugs, urinary alkalizers: and alkaline phosphatase levels. Decreased hypoglycemic effect • Store acetohexamide in tightly sealed con- digitalis glycosides: Possibly increased serum tainer in a cool environment.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 28 28 acetohydroxamic acid PATIENT TEACHING controlled by appropriate antimicrobial • Stress need to adhere to prescribed drug therapy regimen, diet, and exercise program. Interactions • Advise patient to take acetohexamide with DRUGS food to avoid GI upset. iron: Decreased intestinal absorption of • Teach patient how to self-monitor blood iron, decreased effects of iron and acetohy- glucose level and check urine for glucose droxamic acid and ketones, as appropriate. ACTIVITIES • Teach patient to recognize and report alcohol use: Increased risk of severe rash signs of hypoglycemia and hyperglycemia. 30 to 45 minutes after drinking alcohol Adverse Reactions acetohydroxamic CNS: Anxiety, depression, fever, lack of coordination, malaise, headache, nervous- acid ness, slurred speech, tiredness, tremor CV: Calf pain (deep vein blood clot), palpi- Lithostat tations, sudden chest pain EENT: Pharyngitis, sudden change in vision Class and Category GI: Anorexia, nausea, vomiting Chemical class: Synthetic hydroxylamine HEME: Reticulocytosis, unusual bleeding and ethylacetate derivative RESP: Dyspnea Therapeutic class: Urease inhibitor SKIN: Ecchymosis, hair loss, nonpruritic Pregnancy category: X macular rash Indications and Dosages Nursing Considerations  As an adjunct to antimicrobial therapy • Use acetohydroxamic acid cautiously in to treat chronic UTI caused by urea- patients with severe chronic renal disease splitting bacteria or anemia and those who’ve had phlebitis TABLETS or thrombophlebitis. Adults. Initial: 12 mg/kg daily in divided • Be aware that risk of adverse psychomotor doses every 6 to 8 hr. Usual: 250 mg t.i.d. or effects increases if patient drinks alcohol q.i.d. for a total of 10 to 15 mg/kg daily. or takes drugs that affect alertness and Maximum: 1,500 mg daily. reflexes, such as antihistamines, tranquiliz- Children. 10 mg/kg daily. ers, sedatives, analgesics, and narcotics. DOSAGE ADJUSTMENT Maximum dosage • Administer tablets with food or liquid, reduced to 1,000 mg daily or 500 mg every crushing them if needed. 12 hr for patients with serum creatinine WARNING Acetohydroxamic acid chelates level that exceeds 1.8 mg/dl. with dietary iron. If patient has iron defi- ciency anemia, expect to administer I.M. Mechanism of Action iron as needed during acetohydroxamic Inhibits urease, the enzyme that catalyzes acid therapy. urea’s hydrolysis to carbon dioxide and • Monitor follow-up laboratory tests to ammonia in urine infected with urea- check renal and hepatic function and splitting bacteria. This action reduces the urine pH, as ordered. urine ammonia level and pH, enhancing PATIENT TEACHING antimicrobial drug effectiveness. • Instruct patient to take drug at same time Contraindications each day, as prescribed. Contributing disorder that’s treatable by • Tell patient to take a missed dose up to surgery or appropriate antimicrobial thera- 2 hours after scheduled time. If more than py, hypersensitivity to acetohydroxamic 2 hours have passed, he should wait for acid, inadequate renal function (serum cre- next scheduled dose and shouldn’t double atinine level above 2.5 mg/dl or creatinine that dose. clearance below 20 ml/min/1.73 m2), risk of • Warn patient not to take drug with alco- pregnancy, UTI caused by non–urease- hol or iron and to consult prescriber producing organisms, UTI that could be before taking it with any other drug.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 29 acetylcysteine 29 • Instruct patient to avoid hazardous activi- kg in 3 ml/kg of diluent infused over 60 min, ties during therapy. followed by 50 mg/kg in 7 ml/kg of diluent infused over 4 hr, followed by 100 mg/kg in A 14 ml/kg of diluent infused over 16 hr. acetylcysteine Mechanism of Action Acetadote, Mucomyst, Mucosil Decreases viscosity of pulmonary secretions by breaking disulfide links that bind glyco- Class and Category proteins in mucus. Reduces liver damage Chemical class: N-acetyl derivative of from acetaminophen overdose. Usually, cysteine acetaminophen’s toxic metabolites bind Therapeutic class: Antidote (for acetamino- with glutathione in the liver, which detoxi- phen overdose), mucolytic fies them. When acetaminophen overdose Pregnancy category: B depletes glutathione stores, toxic metabo- lites bind with protein in liver cells, killing Indications and Dosages them. Acetylcysteine maintains or restores  To liquefy abnormal, viscid, or thickened levels of glutathione or acts as its substitute, mucus secretions in chronic pulmonary which reduces liver damage from aceta- disorders (including emphysema, bron- minophen overdose. chitis, tuberculosis, bronchiectasis, and cystic fibrosis) and in pneumonia, pul- Incompatibilities monary complications of thoracic or car- Don’t give acetylcysteine with nebulization diovascular surgery, and tracheostomy equipment if drug can contact iron, copper, care or rubber. Don’t give drug with ampho- SOLUTION BY DIRECT INSTILLATION INTO tericin B, ampicillin sodium, chlortetracy- TRACHEOSTOMY (MUCOMYST, MUCOSIL) cline, chymotrypsin, erythromycin, hydro- Adults and children. 1 to 2 ml of 10% or gen peroxide, iodized oil, oxytetracycline, 20% solution instilled every 1 to 4 hr, p.r.n. tetracycline, or trypsin. SOLUTION BY INHALATION Contraindications Adults and children. 1 to 10 ml of 20% Hypersensitivity to acetylcysteine, no solution or 2 to 20 ml of 10% solution neb- contraindications when used as antidote ulized through face mask, mouthpiece, or tracheostomy every 2 to 6 hr. Usual: 3 to Interactions DRUGS 5 ml of 20% solution or 6 to 10 ml of 10% solution t.i.d. or q.i.d. activated charcoal: Possibly adsorption and  To treat acetaminophen overdose decreased effectiveness of oral acetylcys- SOLUTION P.O. (MUCOMYST, MUCOSIL) teine Adults and children. Loading dose: 140 mg/ nitroglycerin: Increased effects of nitroglyc- kg. Maintenance: 70 mg/kg 4 hr after load- erin and possibly significant hypotension ing dose and then every 4 hr to a total of and headache 17 doses. Adverse Reactions I.V. INFUSION (ACETADOTE) CNS: Chills, dizziness, drowsiness, fever, Adults and children weighing 40 kg (88 lb) headache or more. 150 mg/kg in 200 ml of diluent CV: Edema, hypertension, hypotension, infused over 60 min, followed by 50 mg/kg tachycardia in 500 ml of diluent infused over 4 hr, fol- EENT: Rhinorrhea, stomatitis, tooth dam- lowed by 100 mg/kg in 1,000 ml of diluent age infused over 16 hr. GI: Anorexia, constipation, hepatotoxicity, Adults and children weighing more than nausea, vomiting 20 kg (44 lb) but less than 40 kg. 150 mg/ RESP: Bronchospasm, chest tightness, kg in 100 ml of diluent infused over 60 min, cough, hemoptysis, respiratory distress, followed by 50 mg/kg in 250 ml of diluent shortness of breath, stridor, wheezing infused over 4 hr, followed by 100 mg/kg in SKIN: Clammy skin, facial flushing, pruri- 500 ml of diluent infused over 16 hr. tus, rash, urticaria Children weighing 20 kg or less. 150 mg/ Other: Anaphylaxis, angioedema
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 30 30 acitretin Nursing Considerations 96 hours. • Acetylcysteine should be used cautiously • Assess type, frequency, and characteristics in patients with asthma or a history of of patient’s cough. Particularly note spu- bronchospasm because drug may adverse- tum. If cough doesn’t clear secretions, pre- ly affect respiratory function. pare to perform mechanical suctioning. WARNING To avoid fluid overload and pos- • Monitor patient for tachycardia. sibly fatal hyponatremia or seizures, adjust PATIENT TEACHING total administered volume, as ordered, for • Instruct patient to notify prescriber imme- patients weighing less than 40 kg (88 lb) diately about nausea, rash, or vomiting. and for those who need fluid restriction. • Warn patient about acetylcysteine’s • If needed, dilute 20% instillation or unpleasant smell; reassure him that it sub- inhalation solution with normal saline sides as treatment progresses. solution or sterile water. The 10% solution • To decrease mucus viscosity, urge patient may be used undiluted. to consume 2 to 3 L of fluid daily unless • When treating acetaminophen overdose, contraindicated by another condition. dilute 20% oral solution with cola or other soft drink to a concentration of 5%, and use within 1 hour. Dilute parenteral solu- acitretin tion with D5W or half-normal saline (0.45% sodium chloride) solution for Soriatane injection following manufacturer guide- lines because dilution is based on dosage. Class and Category Acetadote may turn from colorless to Chemical class: Synthetic retinoid slight pink or purple once the stopper is Therapeutic class: Antipsoriatic punctured, but color change has no effect Pregnancy category: X on product quality. • Acetylcysteine is most effective if given Indications and Dosages within 24 hours of acetaminophen inges-  To treat severe psoriasis tion. For specific instructions, contact a CAPSULES regional poison center at 1-800-222-1222 Adults. 25 to 50 mg once daily with a meal. or a special health professional assistance hotline at 1-800-525-6115. Route Onset Peak Duration • If patient vomits loading dose or any P.O. Unknown 2–5 hr Unknown maintenance dose within 1 hour of administration, repeat dose as prescribed. Mechanism of Action • Keep in mind that suicidal patient may Binds to several retinoid receptors to regu- not provide reliable information about late gene transcription. Exactly how the vomiting. Watch such a patient to ensure action of this second-generation retinoid that he ingests all of prescribed dosage. allows normal growth and development of • During treatment for acetaminophen skin is unknown. overdose, watch for signs of hepatotoxici- Contraindications ty, such as prolonged bleeding time, Alcohol consumption; blood donation; altered coagulation, and easy bruising. breast-feeding; chronic hyperlipidemia; • Be aware that acetylcysteine may have a concurrent use of etretinate, methotrexate, disagreeable odor, which disappears as or tetracycline; hypersensitivity to acitretin, treatment progresses. other retinoids, or their components; preg- • Because nebulization causes sticky residue nancy; severe hepatic or renal impairment on face and in mouth, have patient wash his face and rinse his mouth at the end of Interactions each treatment. DRUGS • Be aware that an open vial of solution may methotrexate: Increased risk of hepatitis turn light purple but that this doesn’t alter oral contraceptives containing only progestin: its effectiveness. Possibly decreased effectiveness of oral con- • Refrigerate opened vials and discard after traceptive
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 31 acitretin 31 phenytoin: Possibly decreased protein bind- urine or serum pregnancy tests with a sen- ing of phenytoin sitivity of at least 25 mIU/ml before sulfonylureas: Possibly increased risk of receiving acitretin. First test should be A hypoglycemia obtained when decision is made to use tetracyclines: Increased intracranial pressure acitretin and second test during first vitamin A and other oral retinoids: Increased 5 days of the menstrual period just before risk of hypervitaminosis A acitretin therapy starts. For patients with ACTIVITIES amenorrhea, second test should be done at alcohol use: Increased risk of adverse reac- least 11 days after the last act of unpro- tions and acitretin toxicity tected sexual intercourse (which means without using two effective forms of con- Adverse Reactions traception simultaneously). CNS: Aggression, depression, fatigue, • Check to make sure female patient of headache, hyperesthesia, hypotonia, insom- childbearing age has signed the patient nia, intracranial hypertension, paresthesia, agreement and informed consent form peripheral neuropathy, rigors, somnolence, before starting acitretin therapy. stroke, suicidal ideation, thirst • Obtain a lipid profile, as ordered, before CV: Chest pain, decreased high-density acitretin therapy starts and every 1 to lipoproteins, edema, elevated cholesterol or 2 weeks for up to 8 weeks or until lipid triglyceride levels, MI, thromboembolism effects are known. In high-risk patients, EENT: Abnormal or blurred vision, ble- such as those with diabetes, obesity, or a pharitis, conjunctivitis, corneal epithelial history of alcohol abuse and those taking abnormality, decreased night vision, deaf- acitretin long-term, check lipid profile ness, dry eyes or mouth, earache, epistaxis, periodically throughout therapy. eye pain, gingival bleeding, gingivitis, • Monitor liver function test results, as increased saliva, photophobia, sinusitis, ordered. If hepatotoxicity is suspected, stomatitis, taste perversion, tinnitus, ulcera- expect to stop drug and investigate cause. tive stomatitits • If patient takes acitretin long-term or she ENDO: Hot flashes, hyperglycemia develops a skeletal disorder, prepare her GI: Anorexia, abdominal pain, diarrhea, for periodic bone radiography because elevated liver enzymes, hepatitis, hepatotox- ossification abnormalities can occur, espe- icity, nausea, pancreatitis cially of the vertebral column, knees, and GU: Vulvovaginitis ankles. HEME: Hemorrhage, increased bleeding • Monitor patient’s eyes for abnormalities time throughout therapy. Expect patient to stop MS: Arthralgia, arthrosis, back pain, hyper- drug and have an ophthalmologic exami- ostosis, myalgia, myopathy nation if eye abnormalities occur. SKIN: Abnormal skin or hair texture, • Monitor patient for evidence of increased alopecia, bullous eruption, cold or clammy intracranial pressure, such as papilledema, skin, dermatitis, diaphoresis, dry or peeling headache, nausea, vomiting, and visual skin, erythematous rash, flushing, fragility disturbances. If papilledema occurs, stop or thinning of skin, photosensitivity, pruri- drug therapy immediately and obtain a tus, purpura, pyogenic granuloma, rash, neurologic evaluation, as ordered. Patient scaling, seborrhea, skin fissure or ulceration should never receive a tetracycline while Other: Hypervitaminosis A, increased taking acitretin because combined use can appetite increase intracranial pressure. Nursing Considerations • Assess patient for suidical ideation because WARNING Don’t give acitretin to a pregnant depression and other psychiatric symp- woman, a woman contemplating pregnan- toms, including thoughts of self-harm, cy, or a woman who may not use reliable may occur with acitretin use. Expect drug contraception during drug therapy and for to be discontinued if psychiatric symp- at least 3 years afterward because acitretin toms develop. causes major fetal abnormalities. • Significantly lower doses of phototherapy • Make sure patient has had two negative are needed during acitretin therapy
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 32 32 adalimumab because drug increases the risk of erythe- ma. PATIENT TEACHING adalimumab WARNING Warn women of childbearing age HUMIRA that acitretin causes major fetal abnormal- ities. Class and Category • Inform woman of childbearing age that Chemical class: Recombinant human IgG1 she must have a pregnancy test before monoclonal antibody acitretin therapy starts, every month dur- Therapeutic class: Disease-modifying ing acitretin therapy, and every 3 months antirheumatic for 3 years after therapy stops. Pregnancy category: B • Stress to woman of childbearing age that she must use two effective forms of con- Indications and Dosages traception simultaneously unless she has  To reduce signs and symptoms, induce chosen absolute abstinence or has had a major clinical response, inhibit progres- hysterectomy. This must begin at least 1 sion of structural damage, and improve month before acitretin therapy starts and physical function in patients with mod- continue throughout therapy and for at erately to severely active rheumatoid least 3 years after therapy ends. arthritis; to reduce signs and symptoms, • Caution women taking oral contraceptives inhibit progression of structural damage, that some prescribed and OTC drugs, and improve physical function in including herbal supplements such as St. patients with psoriatic arthritis; to John’s wort, may interfere with oral con- reduce signs and symptoms in patients traceptives. Urge her to tell prescriber with active ankylosing spondylitis about all drugs she takes. SUBCUTANEOUS INJECTION • Caution patient not to consume alcohol or Adults. 40 mg every other wk. products that contain alcohol during DOSAGE ADJUSTMENT Dosage may be acitretin therapy and for 2 months after adjusted to 40 mg every wk, as needed and therapy ends. prescribed, for patients not taking • Warn patient, male or female of any age, methotrexate. not to donate blood during acitretin ther-  To reduce signs and symptoms and apy and for at least 3 years after it ends. induce and maintain clinical remission • Review acitretin medication guide with in patients with moderately to severely patient, and answer the patient’s ques- active Crohn’s disease who have had an tions. inadequate response to conventional • Inform patient that psoriasis may worsen therapy or who have stopped responding during initial treatment and that full to or have become intolerant of inflix- effects of drug may not be seen for up to imab 3 months. SUBCUTANEOUS INJECTION • Caution patient to avoid hazardous activi- Adults. Initial: 40 mg q.i.d. for 1 day or ties until drug’s CNS and ophthalmic 40 mg b.i.d. for 2 consecutive days, followed effects are known. by 80 mg 2 wk later. Maintenance: 40 mg • Inform patient that tolerance to contact every other wk starting at week 4. lenses may decrease during acitretin thera-  To reduce signs and symptoms of moder- py and for a period of time after treatment ately to severely active polyarticular ends. juvenile idiopathic arthritis • Advise patient not to take more than the SUBCUTANEOUS INJECTION minimum recommended daily allowance Children age 4 and over who weigh 30 kg of vitamin A during acitretin therapy (66 lb) or more. 40 mg every other wk. because of the risk of vitamin A toxicity. Children age 4 and over who weigh less • Caution patient not to use sun lamps and than 30 kg but at least 15 kg (33 lb). 20 mg to avoid excessive exposure to sunlight every other wk. because the effects of UV light are  To treat moderate to severe chronic enhanced by retinoids such as acitretin. plaque psoriasis in patients who are
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 33 adalimumab 33 candidates for systemic therapy or pho- arthritis); back, extremity, pelvic, or thorax totherapy, and when other systemic ther- pain; bone disorder, fracture, or necrosis; A apies are less appropriate muscle spasms; myasthenia; prosthetic SUBCUTANEOUS INJECTION infections; synovitis Adults. Initial: 80 mg followed 1 wk later RESP: Asthma, bronchitis, bronchospasm, with 40 mg. Maintenance: 40 mg every decreased pulmonary function, dyspnea, other wk. pleural effusion, pneumonia, pulmonary Mechanism of Action tuberculosis, upper respiratory tract infec- Binds to tumor necrosis factor (TNF) to tion block interaction with p55 and p75 cell- SKIN: Cellulitis, erysipelas, erythema mul- surface TNF receptors, and lyses surface tiforme, herpes zoster, new or worsening TNF-expressing cells in the presence of psoriasis, rash, urticaria complement. TNF may be a major com- Other: Anaphylaxis; antibody formation ponent of rheumatoid arthritis inflam- against adalimumab; dehydration; flare-up mation and joint destruction. Reduced TNF of disease process; flulike symptoms; heal- level in synovial fluid improves signs and ing abnormalities; injection site erythema, symptoms and prevents further structural hemorrhage, itching, pain, or swelling; damage in rheumatoid arthritis. invasive fungal infection; lupus-like symp- toms; lymphomas; malignancies; oppor- Contraindications tunistic infection; postsurgical infection; Active infection, breast-feeding, hypersensi- sepsis; tuberculosis (miliary, lymphatic, or tivity to adalimumab or its components peritoneal) Interactions Nursing Considerations DRUGS • Use adalimumab cautiously in patients anakinra: Possibly increased risk of serious with recurrent infection or increased risk infection and neutropenia of infection, patients who live in regions live vaccines: Increased risk of adverse vac- where tuberculosis and mycoses are cine effects endemic, and patients with a history of Adverse Reactions CNS demyelinating disorders because they CNS: Confusion, fever, headache, hyperten- occur, rarely, during adalimumab therapy. sive encephalopathy, multiple sclerosis, WARNING If patient has evidence of an paresthesia, subdural hematoma, syncope, active infection when drug is prescribed, tremor therapy shouldn’t start until infection has CV: Arrhythmias, atrial fibrillation, cardiac been treated. Monitor all patients for arrest, chest pain, coronary artery disease, infection during therapy, especially those congestive heart failure, hypercholesterol- receiving immunosuppressants. If a seri- emia, hyperlipidemia, hypertension, MI, ous infection develops, expect prescriber palpitations, pericardial effusion, pericardi- to stop drug. tis, peripheral edema, tachycardia • Make sure patient has a tuberculin skin EENT: Cataracts, sinusitis test before therapy starts. If skin test is ENDO: Ketosis, parathyroid disorder positive, treatment of latent tuberculosis GI: Abdominal pain, cholecystitis, will start before adalimumab, as pre- cholelithiasis, diverticulitis, elevated alkaline scribed. phosphatase level, elevated liver enzyme lev- • Be aware that the needle cover of the els, esophagitis, gastroenteritis, hemorrhage, syringe contains dry rubber. Don’t handle hepatic necrosis, nausea, vomiting if you’re allergic to latex. GU: Hematuria, paraproteinemia, • To activate the protection device on nee- pyelonephritis, UTI dles of prefilled syringes delivered to insti- HEME: Agranulocytosis, aplastic anemia, tutions, hold the syringe in one hand and, granulocytopenia, leukopenia, lymphocyto- with the other hand, slide outer protective sis, pancytopenia, polycythemia, thrombo- shield over exposed needle until it locks cytopenia into place. MS: Arthritis (including pyogenic or septic WARNING Stop adalimumab immediately
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 34 34 adenosine and tell prescriber if patient has an allergic towel soaked with cold water on the injec- reaction. Expect to provide supportive tion site if it hurts or remains swollen. If care. reaction does not disappear or seems to • Watch closely for evidence of congestive worsen, tell patient to call prescriber heart failure (sudden, unexplained weight immediately. gain; dyspnea; crackles; anxiety), and noti- • Inform patient that tuberculosis may fy prescriber if they occur. occur during adalimumab therapy. • Monitor patient’s CBC, as ordered, Instruct him to report persistent cough, because adalimumab may have adverse wasting or weight loss, and low-grade hematologic effects. Notify prescriber fever to prescriber. about persistent fever, bruising, bleeding, • Teach patient to recognize evidence of or pallor. infection and bleeding disorders and to • Be aware that adalimumab belongs to a tell prescriber if they occur; drug may group of drugs called tumor necrosis fac- need to be stopped. Advise patient to tor (TNF) blockers. Although rare, malig- avoid people with infections and to have nancies, especially lymphomas and all prescribed laboratory tests. leukemias, have occurred in patients receiv- • Inform patient that the risk of certain ing TNF blockers, including children. kinds of cancer, especially lymphomas, is Patients with rheumatoid arthritis, espe- higher in patients taking adalimumab but cially those with very active disease, are at still rare. Emphasize the importance of greatest risk. Monitor patients closely. follow-up visits and reporting an unusual PATIENT TEACHING or sudden onset of signs or symptoms. vInform patient that the first injection of • Caution patient against receiving live- adalimumab must take place with a health virus vaccines while taking adalimumab care professional present. because doing so may adversely effect the • Teach patient or caregiver how to give immune system. adalimumab as a subcutaneous injection • Inform patient that blood samples may be at home, if applicable. Emphasize impor- needed periodically, but especially around tance of injecting the full amount in the week 24 of therapy, to check for autoanti- syringe (0.8 ml) to obtain the correct dose body development. Explain that adali- of 40 mg. mumab therapy will need to be stopped if • If patient is allergic to latex, explain that they’re detected. the needle cover contains rubber. • Instruct patient to report lupus-like signs • Caution patient against reusing needles and symptoms that, although rare, may and syringes. Provide patient or caregiver occur during therapy, such as chest pain with a puncture resistant container for that doesn’t go away, shortness of breath, disposal of needles and syringes at home. joint pain, or a rash on cheeks or arms • Instruct patient or caregiver to rotate that’s sensitive to the sun. Explain that injection sites and to avoid injecting in any drug may be stopped if these occur. area that’s tender, bruised, red, or hard. • Advise patient to inform all health care • Inform patient that prefilled syringes must providers about adalimumab use and to be refrigerated (not frozen), protected inform prescriber about any OTC medica- from light, and stored in the original con- tions being taken, including herbal reme- tainer. dies and vitamin and mineral supple- • Urge patient to check expiration dates and ments. not to use outdated drug. • Review signs and symptoms of an allergic reaction (rash, swollen face, difficulty adenosine breathing), and tell patient to seek emer- gency care immediately if these occur. Adenocard, Adenoscan • Inform patient that injection site reactions (such as redness, rash, swelling, itching, Class and Category and bruising) may occur but are usually Chemical class: Monophosphorylated mild and transient. Instruct him to apply a adenine riboside
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 35 adenosine 35 Therapeutic class: Antiarrhythmic heaviness in arms, light-headedness, nerv- Pregnancy category: C ousness, paresthesia, seizures CV: Atrial fibrillation, bradycardia, chest A Indications and Dosages  To convert paroxysmal supraventricular pain or pressure, heart block, hypertension, hypotension, MI, palpitations, prolonged tachycardia (PSVT) to normal sinus asystole, sinus exit block or pause, torsades rhythm de pointes, transient hypertension, ventric- I.V. INJECTION ular fibrillation, ventricular tachycardia Adults and children weighing 50 kg (110 EENT: Blurred vision, metallic taste, throat lb) or more. Initial: 6 mg by rapid periph- tightness eral I.V. bolus over 1 to 2 sec. If PSVT con- GI: Nausea, vomiting tinues after 1 to 2 min, 12 mg given as rapid MS: Jaw, neck, and back pain bolus and repeated in 1 to 2 min if needed. RESP: Bronchoconstriction, bronchospasm, Don’t give single doses of more than 12 mg. dyspnea, hyperventilation, respiratory arrest Children weighing less than 50 kg. Initial: SKIN: Diaphoresis, facial flushing 0.05 to 0.1 mg/kg as rapid central or Other: Injection site reaction peripheral I.V. bolus followed by saline flush. If PSVT continues after 1 to 2 min, Nursing Considerations additional bolus injections are given, incre- • Before use, inspect adenosine for crystals. mentally increasing dose by 0.05 to 0.1 mg/ If solution isn’t clear, don’t give it. kg. Follow each bolus with saline flush. • Give adenosine by rapid I.V. bolus over 1 Injections continue until PSVT converts to to 2 seconds. Slower delivery can cause normal sinus rhythm or until patient reach- systemic vasodilation and reflex tachycar- es maximum single dose of 0.3 mg/kg. dia. • Expect prescriber to inject adenosine Route Onset Peak Duration directly into a vein to make sure drug I.V. Immediate Immediate Unknown reaches systemic circulation. If given into an I.V. line, give drug as close to insertion Mechanism of Action site as possible and follow with rapid Slows conduction time through the AV saline flush. node and can interrupt AV node reentry WARNING Don’t give single doses of more pathways to restore normal sinus rhythm. than 12 mg. • Monitor heart rate and rhythm, blood Incompatibilities pressure, and respiratory status often dur- Don’t mix adenosine with other drugs. ing adenosine therapy. Contraindications • Be aware that at the time of conversion to Atrial fibrillation or flutter; hypersensitivity normal sinus rhythm, arrhythmias (such to adenosine; second- or third-degree heart as PVCs, premature atrial contractions, block or sick sinus syndrome, except in sinus bradycardia, sinus tachycardia, and patients with a functioning artificial pace- AV block) may occur for a few seconds, maker; ventricular tachycardia but they don’t usually require interven- tion. Interactions WARNING Stop drug use and notify pre- DRUGS scriber immediately if severe respiratory carbamazepine: Increased heart block difficulties develop. digoxin, verapamil: Possibly increased • Store adenosine at room temperature. depressant effect on SA or AV node Discard unused portion. dipyridamole: Increased adenosine effects PATIENT TEACHING methylxanthines, such as theophylline: • Instruct patient to report chest pain, pal- Antagonized adenosine effects pitations, difficulty breathing, or severe FOODS headache during adenosine therapy. caffeine: Antagonized adenosine effects • Warn patient that mild, temporary reac- Adverse Reactions tions may occur, such as flushing, nausea, CNS: Apprehension, dizziness, headache, and dizziness.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 36 36 alatrofloxacin mesylate anaerobic bacteria. May be active against alatrofloxacin pathogens resistant to such antibiotics as penicillins, cephalosporins, aminoglyco- mesylate sides, macrolides, and tetracyclines. Trovan I.V. Incompatibilities trovafloxacin Don’t mix alatrofloxacin with or infuse it simultaneously through same I.V. line as mesylate other drugs. Don’t dilute it with normal Trovan saline solution or lactated Ringer’s solution. Contraindications Class and Category Hypersensitivity to alatrofloxacin, quino- Chemical class: Fluoroquinolone lone antimicrobials, trovafloxacin, or their Therapeutic class: Antibacterial components Pregnancy category: C Interactions Indications and Dosages DRUGS  To treat life-threatening nosocomial antacids that contain aluminum, citric acid, pneumonia magnesium, or sodium citrate; iron; mor- TABLETS, I.V. INFUSION phine sulfate; sucralfate: Reduced absorption Adults. 300 mg I.V. every 24 hr followed by of trovafloxacin 200 mg P.O. every 24 hr when patient is sta- bilized for total of 10 to 14 days. Adverse Reactions  To treat life-threatening community- CNS: Dizziness, headache, light-headed- acquired pneumonia ness, seizures TABLETS, I.V. INFUSION CV: Hypotension Adults. 200 mg I.V. every 24 hr followed by EENT: Hoarseness, throat tightness 200 mg P.O. every 24 hr when patient is sta- GI: Abdominal pain, acute hepatic failure bilized for total of 7 to 14 days; or 200 mg (anorexia, dark urine, dysphagia, fatigue, P.O. every 24 hr for total of 7 to 14 days. jaundice, pale stool, and vomiting)  To treat complicated, life-threatening GU: Vaginitis intra-abdominal infections, including RESP: Dyspnea postsurgical, gynecologic, and pelvic SKIN: Photosensitivity, rash, urticaria or infections other skin reactions TABLETS, I.V. INFUSION Other: Angioedema Adults. 300 mg I.V. every 24 hr followed by Nursing Considerations 200 mg P.O. every 24 hr when patient is sta- • Infuse alatrofloxacin over 60 minutes; bilized for total of 7 to 14 days. rapid or bolus I.V. delivery may cause  To treat complicated, life-threatening or hypotension. limb-threatening skin and soft-tissue • Periodically assess patient’s liver function infections, including diabetic foot infec- test results. Results may be elevated for up tions to 21 days after alatrofloxacin use. TABLETS, I.V. INFUSION WARNING Be aware that alatrofloxacin may Adults. 200 mg P.O. every 24 hr—or 200 cause severe liver damage, requiring liver mg I.V. every 24 hr followed by 200 mg P.O. transplantation or leading to death. Expect every 24 hr when patient is stabilized—for therapy to last no longer than 2 weeks to total of 10 to 14 days. reduce risk of liver damage. Alatrofloxacin DOSAGE ADJUSTMENT For patients with is reserved for hospitalized patients with mild to moderate cirrhosis, 300-mg I.V. life- or limb-threatening infections. dosage reduced to 200 mg and 200-mg I.V. PATIENT TEACHING and P.O. dosage reduced to 100 mg. • Instruct patient to report rash; urticaria; Mechanism of Action trouble swallowing; swelling of the lips, Interferes with DNA gyrase, the enzyme face, or tongue; hoarseness; or throat needed for DNA replication in aerobic and tightness.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 37 albuterol 37 TABLETS albuterol Adults and children over age 12. Initial: A 2 or 4 mg t.i.d. or q.i.d. Maximum: 32 mg (salbutamol) daily in divided doses. Proventil Children ages 6 to 12. Initial: 2 mg t.i.d. or q.i.d. Maximum: 24 mg daily in divided albuterol sulfate doses. DOSAGE ADJUSTMENT For elderly patients, (salbutamol sulphate) initial dosage reduced to 2 mg (1 tsp) of AccuNeb, Airet, Gen-Salbutamol (CAN), syrup t.i.d. or q.i.d. or 2 mg of tablets t.i.d. Novo-Salmol (CAN), Proair HFA, or q.i.d. (up to 32 mg daily). Proventil, Proventil HFA, Proventil INHALATION AEROSOL Repetabs, Proventil Syrup, Ventolin Adults and children age 4 and over. 1 in- HFA, Ventolin Syrup, Volmax halation every 4 hr to 2 inhalations every 4 to 6 hr. Class and Category INHALATION CAPSULES (ROTOCAPS) Chemical class: Selective beta2-adrenergic Adults and children age 4 and over. agonist, sympathomimetic 200 mcg inhaled every 4 to 6 hr using Therapeutic class: Bronchodilator inhalation device. Maximum: 400 mcg Pregnancy category: C every 4 to 6 hr. INHALATION SOLUTION Indications and Dosages Adults and children age 12 and over.  To prevent exercise-induced asthma 2.5 mg t.i.d. or q.i.d. by nebulization over INHALATION AEROSOL 5 to 15 min. Adults and children over age 4. 2 inhala- Children ages 2 to 12. Initial: 0.1 to tions 15 to 30 min before exercise. 0.15 mg/kg t.i.d. or q.i.d. Maximum: 2.5 mg  To treat bronchospasm in patients with t.i.d. or q.i.d. reversible obstructive airway disease or acute bronchospastic attack Route Onset Peak Duration E.R. TABLETS P.O. (E.R. tab) 30 min 2–3 hr 12 hr Adults and children over age 12. Initial: 4 or 8 mg every 12 hr. Maximum: 32 mg P.O. (syrup) Rapid 2 hr Unknown daily in divided doses every 12 hr. P.O. (tab) 30 min 2–3 hr 4–8 hr Children ages 6 to 12. Initial: 4 mg every Inhalation 5–15 50–55 3–6 hr 12 hr. Maximum: 24 mg daily in divided (aerosol) min min doses every 12 hr. Inhalation 5–15 0.5–3 2–6 hr REPETABS (rotocap) min hr Adults and children over age 12. Initial: Inhalation 5–15 1–2 hr 3–6 hr 4 to 8 mg every 12 hr. Maximum: 32 mg (solution) min daily in divided doses every 12 hr. Children ages 6 to 11. Initial: 4 mg every Contraindications 12 hr. Maximum: 24 mg daily in divided Hypersensitivity to albuterol or its compo- doses every 12 hr. nents SYRUP Adults and children over age 14. Initial: Interactions 2 to 4 mg (1 to 2 tsp) t.i.d. or q.i.d. DRUGS Maximum: 32 mg daily in divided doses. beta blockers: Inhibited effects of albuterol Children ages 6 to 14. Initial: 2 mg (1 tsp) bronchodilators (sympathomimetics), such as t.i.d. or q.i.d. Maximum: 24 mg daily in theophylline: Possibly adverse CV effects divided doses. digoxin: Decreased serum digoxin level Children ages 2 to 6. Initial: 0.1 mg/kg MAO inhibitors, tricyclic antidepressants: t.i.d. (not to exceed 2 mg t.i.d.), increased Increased vascular effects of albuterol to 0.2 mg/kg t.i.d. (not to exceed 4 mg methyldopa: Increased vasopressor effect of t.i.d.). methyldopa
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 38 38 alefacept Mechanism of Action Albuterol Bronchial cell Albuterol attaches to beta2 receptors on membrane bronchial cell membranes, which stimu- Beta2 receptor lates the intracellular enzyme adenylate cyclase to convert adenosine triphosphate (ATP) to cyclic adenosine monophos- phate (cAMP). This reaction decreases intracellular calcium levels. It also increases intracellular levels of cAMP, as shown. Together, these effects relax bronchial smooth-muscle cells and inhib- ATP Adenylate cAMP it histamine release. cyclase potassium-lowering drugs: Possibly hypo- • Monitor serum potassium level because kalemia albuterol may cause transient hypo- potassium-wasting diuretics: Possibly kalemia. increased hypokalemia • Be aware that drug tolerance can develop with prolonged use. Adverse Reactions PATIENT TEACHING CNS: Anxiety, dizziness, drowsiness, head- • Teach patient to use inhaler. Tell him to ache, hyperkinesia, insomnia, irritability, shake canister before use and to check that nervousness, tremor, vertigo, weakness a new canister is working by spraying it CV: Angina; arrhythmias, including atrial the appropriate number of times (once to fibrillation, extrasystoles, supraventricular four times based on manufacturer instruc- tachycardia, and tachycardia; chest pain; tions) into the air while looking for a fine hypertension; hypotension; palpitations mist. EENT: Altered taste, dry mouth and throat, • Instruct patient to wash mouthpiece with ear pain, glossitis, hoarseness, oropharyn- water once a week and let it air-dry. geal edema, pharyngitis, rhinitis, taste per- • Advise patient to wait at least 1 minute version between inhalations. ENDO: Hyperglycemia • Tell patient to check with his prescriber GI: Anorexia, diarrhea, dysphagia, heart- before using other inhaled drugs. burn, nausea, vomiting • Warn patient not to exceed prescribed GU: UTI dose or frequency. If doses become less MS: Muscle cramps effective, tell patient to contact his pre- RESP: Bronchospasm, cough, dyspnea, par- scriber. adoxical bronchospasm, pulmonary edema • Tell patient to immediately report signs SKIN: Diaphoresis, flushing, pallor, pruri- and symptoms of allergic reaction, such as tus, rash, urticaria difficulty swallowing, itching, and rash. Other: Angioedema, hypokalemia, infec- tion, metabolic acidosis Nursing Considerations alefacept • Administer pressurized inhalations of albuterol during second half of inspira- Amevive tion, when airways are open wider and aerosol distribution is more effective. Class and Category WARNING Use cautiously in patients with Chemical class: Recombinant leukocyte cardiac disorders, diabetes mellitus, digi- function-associated antigen-3 talis intoxication, hypertension, hyperthy- immunoglobulin GI fusion protein roidism, or history of seizures. Albuterol Therapeutic class: Immunosuppresant can worsen these conditions. Pregnancy category: B
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 39 alefacept 39 Indications and Dosages risk of infection because of its immuno-  To treat moderate to severe chronic suppressive action. plaque psoriasis in patients who are • Obtain a CD4+ and T-lymphocyte count A candidates for systemic therapy or pho- before starting alefacept therapy, as totherapy ordered. If counts are below normal, be I.V. INJECTION aware that therapy shouldn’t be started. Adults. Initial: 7.5 mg every wk for 12 wk. After therapy starts, monitor patient’s After at least 12 wk in which drug isn’t CD4+ and T-lymphocyte counts weekly given, a second 12-wk course may be given, throughout therapy. If levels drop below if needed and if patient’s CD4 and T-lym- 250 cells/microliter, notify prescriber phocyte counts are within normal ranges. because drug will need to be withheld. If I.M. INJECTION counts remain below 250 cells/microliter Adults. 15 mg every week for 12 wk. After for 1 month, expect that drug will be dis- at least 12 wk in which drug isn’t given, a continued. second 12-wk course may be given, if need- • Reconstitute drug with 0.6 ml using only ed and if patient’s CD4 and T-lymphocyte the supplied diluent (sterile water for counts are within normal ranges. injection) before administration. With the needle pointed at sidewall of vial, slowly Mechanism of Action inject diluent into vial of alefacept. Be Interferes with T-lymphocyte activation by aware that some foaming will occur. To binding to lymphocyte antigen and CD2, prevent excessive foaming, don’t shake or inhibiting LFA-3/CD2 interaction, and vigorously agitate vial. Instead, gently swirl reducing the subsets of CD2+ T lympho- vial during dissolution, which usually cytes. This interference helps prevent plaque takes less than 2 minutes. formation in chronic plaque psoriasis. • Administer drug as soon as possible after Incompatibilities reconstitution. Discard solution if not Don’t add other drugs to solutions contain- used within 4 hours. ing alefacept. • Don’t filter reconstituted solution during preparation or administration. Contraindications • For I.M. administration, inject the full Breast-feeding, hypersensitivity to alefacept 0.5 ml of solution. Use a different injec- or its components tion site for each subsequent injection, Adverse Reactions injecting at least 1 inch away from previ- CNS: Chills, dizziness, headache ous sites. Never inject the drug into tender, CV: Coronary artery disease, MI bruised, red, or hard areas. EENT: Pharyngitis • For I.V. administration, prepare two GI: Nausea syringes with 3 ml normal saline solution HEME: Lymphopenia for preadministration and post- MS: Myalgia administration flush. Then prime the RESP: Increased cough winged infusion set with 3 ml normal SKIN: Pruritus, urticaria saline solution and insert into vein. Attach Other: Angioedema, injection site pain or filled syringe to infusion set, and adminis- inflammation, infection, malignancies ter solution over no more than 5 seconds. Finish by flushing set with 3 ml of normal Nursing Considerations saline solution. • Use alefacept cautiously in patients at high • Be aware that drug shouldn’t be started in risk for malignancy because the drug a patient with a concurrent serious infec- increases risk of malignancy development. tion. Monitor patient closely during and Know that drug isn’t recommended for after therapy for signs and symptoms of use in patients with a history of a systemic infection. If these occur, report them to malignancy. the prescriber immediately and begin • Also use alefacept cautiously in patients treatment, as prescribed, to reduce risk of with chronic infections or history of serious infection. If infection becomes recurrent infection. Drug may increase serious, expect drug to be discontinued.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 40 40 alendronate sodium • Monitor patient for allergic reactions. If the morning with a full glass of water at these occur, discontinue drug and notify least 30 min before first food, drink, or prescriber immediately. drug. PATIENT TEACHING  To treat glucocorticoid-induced osteo- • Advise patient that weekly blood tests will porosis in men and women who receive be required to monitor his WBC count a daily glucocorticoid dosage of 7.5 mg during alefacept therapy. of greater of prednisone and who have • Teach patient signs and symptoms of low bone mineral density infection and common warning signs of TABLETS malignancy. Emphasize importance of Adults. 5 mg daily in the morning with a complying with follow-up visits and full glass of water at least 30 min before promptly reporting any unusual or sudden first food, drink, or drug. signs or symptoms suggesting malignancy or infection. Route Onset Peak Duration • Instruct female patient to notify prescriber P.O. Unknown Unknown 6 wk* if she becomes pregnant while taking ale- facept or within 8 weeks after stopping it. Mechanism of Action Reduces activity of cells that cause bone loss, slows rate of bone loss after meno- alendronate sodium pause, and increases amount of bone mass. May act by inhibiting osteoclast activity on Fosamax newly formed bone resorption surfaces, which reduces the number of sites where Class and Category bone is remodeled. Bone formation then Chemical class: Aminobisphosphonate exceeds bone resorption at these remodel- Therapeutic class: Bone resorption inhibitor ing sites, which gradually increases bone Pregnancy category: C mass. May also inhibit bone dissolution by Indications and Dosages binding to hydroxyapatite crystals, which  To prevent postmenopausal osteoporosis are composed of calcium, phosphate, and TABLETS hydroxide and give bone its rigid structure. Adults. 5 mg daily or 35 mg once/wk in the Contraindications morning with a full glass of water at least Esophageal abnormalities that delay esoph- 30 min before first food, drink, or drug. ageal emptying, such as stricture or achala-  To treat postmenopausal osteoporosis sia; hypersensitivity to alendronate; TABLETS hypocalcemia; inability to stand or sit Adults. 10 mg daily or 70 mg once/wk in upright for at least 30 minutes the morning with a full glass of water at least 30 min before first food, drink, or Interactions drug. DRUGS  To treat Paget’s disease of the bone in antacids, calcium, iron, multivalent cations: patients whose alkaline phosphatase Decreased absorption of alendronate level is twice the upper limit of normal aspirin: Increased risk of GI distress or higher and who are symptomatic and FOODS at risk for further complications any food: Delayed absorption and decreased TABLETS serum level of alendronate Adults. 40 mg daily with a full glass of Adverse Reactions water for 6 mo. CNS: Asthenia, dizziness, headache, vertigo DOSAGE ADJUSTMENT Dosage increased to CV: Peripheral edema 10 mg daily for postmenopausal women GI: Abdominal distention and pain, consti- not receiving estrogen.  To increase bone mass in men with osteo- porosis * After single 5-mg dose for osteoporosis; TABLETS 6 mo after single 5-mg dose for Paget’s Adults. 10 mg daily or 70 mg once/wk in disease.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 41 alfuzosin hydrochloride 41 pation, diarrhea, dysphagia, esophageal per- Therapeutic class: Selective alpha1- foration or ulceration, esophagitis, flatu- adrenergic antagonist lence, gastritis, gastroesophageal reflux dis- Pregnancy category: B A ease, heartburn, indigestion, melena, nau- sea, vomiting Indications and Dosages  To treat signs and symptoms of benign MS: Arthralgia, bone pain, focal osteomala- cia, joint swelling, muscle spasms, myalgia prostatic hyperplasia E.R. TABLETS SKIN: Photosensitivity, pruritus, rash, Stevens-Johnson syndrome, toxic epidermal Adults. 10 mg daily taken immediately after necrolysis same meal each day. Other: Hypocalcemia Mechanism of Action Nursing Considerations Selectively blocks alpha1-adrenergic recep- • Monitor patient’s serum calcium level tors in smooth muscle of the bladder neck before, during, and after treatment. Expect and prostate, causing relaxation, and blocks hypocalcemia to be treated before alen- postsynaptic alpha1 adrenoreceptors in the dronate therapy. If hypocalcemia occurs bladder base and neck, prostate, prostatic during therapy, expect prescriber to order capsule, and urethra, preventing further a calcium supplement. action at these sites. These actions improve • Ensure adequate dietary intake of calcium urine flow and bladder emptying and and vitamin D before, during, and after reduce urinary hesitancy, frequency, and treatment. nocturia. WARNING Alendronate may irritate upper Contraindications GI mucosa, causing adverse reactions such Hypersensitivity to alfuzosin or its compo- as esophageal ulceration. To help mini- nents, moderate or severe hepatic insuffi- mize these reactions, have patient take ciency, use with CYP3A4 inhibitors, such as drug with a full glass of water and remain itraconazole, ketoconazole, and ritonavir upright for at least 30 minutes. PATIENT TEACHING Interactions DRUGS • Advise patient to take alendronate in the morning with a full glass of water. Explain alpha blockers: May potentiate alfuzosin that beverages such as orange juice, coffee, action and mineral water reduce alendronate’s antihypertensives, nitrates: Possibly synergis- effects. tic lowering of blood pressure and syncope • To help reduce esophageal irritation, tell CYP3A4 inhibitors (such as itraconazole, patient not to chew or suck on tablet. ketoconazole, ritonavir): Increased alfuzosin • Instruct patient to wait at least 30 minutes effects after taking alendronate before eating, Adverse Reactions drinking, or taking other drugs. Teach CNS: Dizziness, fatigue, headache patient to remain upright for 30 minutes CV: Angina, chest pain, edema, orthostatic after taking alendronate and until she has hypotension, QT-interval prolongation, eaten the first food of the day. tachycardia • Encourage patient to consume adequate EENT: Intraoperative floppy iris syndrome, daily amounts of calcium and vitamin D. pharyngitis, rhinitis, sinusitis GI: Abdominal pain, constipation, diarrhea, indigestion, jaundice, hepatotoxicity, nausea alfuzosin GU: Impotence, priapism RESP: Bronchitis, upper respiratory tract hydrochloride infection SKIN: Flushing, pruritus, rash, urticaria Uroxatral Other: Angioedema, generalized pain Class and Category Nursing Considerations Chemical class: Tetrahydro-2- • Use alfuzosin cautiously in patients who furancarboxamide hydrochloride have symptomatic hypotension or who
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 42 42 alglucerase have had a hypotensive response to other DOSAGE ADJUSTMENT Highly individualized drugs. Orthostatic hypotension (with or based on body size and disease severity. without symptoms such as dizziness) may Some patients may need infusion once occur within hours after alfuzosin admin- every other day; others may need it once istration. every 4 wk. Maintenance dosage progres- • Use cautiously in patients with severe sively reduced every 3 to 6 mo to as low as renal insufficiency; decreased drug clear- 1 unit/kg. ance may increase risk of adverse reac- tions. Route Onset Peak Duration • Be aware that alfuzosin shouldn’t be used I.V. Up to Unknown Variable to treat bladder symptoms in women. 60 min • Know that alpha1 blockers such as alfu- zosin may predispose patients to intraop- Mechanism of Action erative floppy iris syndrome during Catalyzes hydrolysis of glucocerebroside to cataract surgery that may require surgical glucose and ceramide in membrane lipids. repair. Gaucher’s disease results from deficiency of • Monitor patient for chest pain. If symp- the enzyme beta-glucocerebrosidase and toms of angina pectoris occur or worsen, causes the lipid glucocerebroside to accu- notify prescriber immediately and expect mulate in tissue macrophages. drug to be discontinued. PATIENT TEACHING Contraindications • Stress need to take alfuzosin immediately Hypersensitivity to alglucerase after a meal because absorption is decreased by 50% if taken on an empty Adverse Reactions stomach. CNS: Chills, dizziness, fatigue, fever, head- • Tell patient not to crush or chew tablets ache but to swallow them whole. CV: Transient peripheral edema, vasomotor • Caution patient to avoid hazardous activi- irritability ties until drug’s CNS effects are known EENT: Oral ulcerations and also for several hours after taking GI: Abdominal discomfort, diarrhea, nau- dose; blood pressure may drop suddenly sea, vomiting after use. MS: Backache Other: I.V. site burning, itching, or swelling Nursing Considerations alglucerase • Before starting alglucerase therapy, expect Ceredase to give antihistamines if patient is hyper- sensitive to drug. Class and Category • On day of dose, use aseptic technique to Chemical class: Glucocerebrosidase beta- dilute alglucerase with normal saline solu- glucosidase tion to final volume of no more than Therapeutic class: Enzyme replacement 200 ml. Pregnancy category: C • Don’t shake drug because doing so could inactivate it. Indications and Dosages • Don’t use alglucerase if it’s discolored or  To treat chronic nonneuropathic contains precipitate. Gaucher’s disease in patients with mod- • Be aware that drug doesn’t contain preser- erate to severe anemia, thrombocytope- vatives. Discard unused portion. nia with bleeding tendencies, bone dis- • Infuse drug with in-line I.V. particle filter. ease, or significant hepatomegaly or PATIENT TEACHING splenomegaly • Tell patient that he may experience flulike I.V. INFUSION symptoms with each dose of alglucerase. Adults and children age 2 and over. • Instruct patient to report headache, hot Individualized. 2.5 units/kg to 60 units/kg flashes, nausea, and other adverse reac- infused over 1 to 2 hr, usually every 2 wk. tions.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 43 aliskiren 43 • Inform patient that alglucerase is derived Increased aliskiren blood level from pooled human placental tissue and furosemide: Decreased blood furosemide poses a slight risk of viral contamination. levels A • Advise patient to keep appointments for irbesartan: Decreased blood aliskiren level scheduled doses of alglucerase. Adverse Reactions CNS: Dizziness, fatigue, headache, seizures CV: Hypotension aliskiren EENT: Nasopharyngitis Tekturna GI: Abdominal pain, diarrhea, dyspepsia, gastroesophageal reflux GU: Renal calculi Class and Category HEME: Decreased hemoglobin and hemat- Chemical class: Hemifumarate salt ocrit Therapeutic class: Antihypertensive (direct MS: Back pain renin inhibitor) RESP: Increased cough, upper respiratory Pregnancy category: C (first trimester), D tract infection (second and third trimester) SKIN: Rash Indications and Dosages Other: Angioedema of head and neck, ele-  To treat hypertension vated creatine kinase or uric acid level, TABLETS gout, hyperkalemia Adults. 150 mg once daily, increased to Nursing Considerations 300 mg once daily, as needed. • Use cautiously in patients with a history of dialysis or who have moderate to severe Route Onset Peak Duration renal dysfunction; it isn’t known whether P.O. Unknown 1–3 hr Unknown nephritic syndrome and renovascular hypertension are adverse effects of Mechanism of Action aliskiren. Inhibits renin secreted by the kidneys in • To prevent hypotension, take measures to response to decreased blood volume and correct volume or salt depletion from renal perfusion. Renin cleaves angioten- high-dose diuretic therapy before starting sinogen to form angiotensin I, which is aliskiren. If hypotension occurs during converted to angiotensin II by ACE and aliskiren therapy, place patient in a supine non-ACE pathways. Angiotension II is a position and give normal saline solution powerful vasoconstrictor that induces intravenously, as needed and prescribed. release of catecholamines from the adrenal WARNING Watch closely for angioedema of medulla and prejunctional nerve endings. It the head or neck. If angioedema occurs, also promotes aldosterone secretion and discontinue aliskiren, notify prescriber, sodium reabsorption. Together, these and provide supportive therapy until actions increase blood pressure. By inhibit- swelling has ceased. If swelling of the ing renin release, aliskiren impairs the tongue, glottis, or larynx is involved, be renin-angiotensin-aldosterone system. prepared to give epinephrine solution Without the vasoconstrictive effect of 1:1,000 (0.3 ml to 0.5 ml), as prescribed, angiotension II, blood pressure decreases. and provide measures to ensure a patent airway. Be aware that patient shouldn’t Contraindications receive aliskiren again. Hypersensitivity to aliskiren or its compo- • Monitor serum potassium level as ordered nents; pregnancy; renal impairment, dis- in patients who are diabetic and also ease, or failure receiving ACE inhibitor therapy because Interactions hyperkalemia may occur. Also monitor DRUGS serum electrolytes, as ordered, especially in ACE inhibitors (diabetics): Increased risk of patients wth severe renal impairment. hyperkalemia PATIENT TEACHING atorvastatin, cyclosporin, ketoconazole: • Advise patient to avoid high-fat meals
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 44 44 allopurinol while taking aliskiren because fat decreases TABLETS drug absorption significantly. Children ages 6 to 10. 300 mg daily, adjust- • Instruct patient how to monitor blood ed after 48 hr, depending on response to pressure to determine effectivenss of treatment. aliskiren therapy. Children under age 6. 150 mg daily, adjust- • Explain that decreased blood pressure ed after 48 hr, depending on response to could lead to light-headedness, especially treatment. in the first few days of therapy. Advise  To prevent gout attack patient to change positions slowly and, if TABLETS light-headedness develops, to notify pre- Adults. 100 mg daily increased by 100 mg/ scriber. Tell patient to stop taking aliskiren wk until serum uric acid level is 6 mg/dl or and to notify prescriber if she faints. less. • Explain that light-headedness and fainting  To prevent uric acid nephropathy during could also result from dehydration caused vigorous treatment of neoplastic disease by inadequate fluid intake, excessive per- TABLETS spiration, diarrhea, or vomiting. Adults. 600 to 800 mg daily for 2 to 3 days, • Instruct patient to avoid using potassium then adjusted to keep serum uric acid level supplements or potassium salt substitutes within normal limits. and to inform all prescribers about her  To treat recurrent calcium oxalate aliskiren and ACE inhibitor therapy. calculi • Stress importance of stopping aliskiren TABLETS and seeking immediate medical attention Adults. 200 to 300 mg daily as a single dose if patient has swelling of face, extremities, or in divided doses, adjusted based on 24- eyes, lips, or tongue or if patient has trou- hr urine urate level. ble swallowing or breathing. DOSAGE ADJUSTMENT For patient with • Instruct female patient to notify prescriber impaired renal function, dosage adjusted to immediately if she is or could be pregnant 200 mg daily if creatinine clearance is 10 to because drug will need to be discontinued 20 ml/min/1.73 m2, 100 mg daily if creati- and another antihypertensive chosen. nine clearance is 3 to 10 ml/min/1.73 m2, or 100 mg every other day if creatinine clear- ance falls below 3 ml/min/1.73 m2. allopurinol  To treat increased serum and urine uric acid levels in patients with leukemia, Apo-Allopurinol (CAN), Lopurin, lymphoma, and solid tumors whose can- Purinol (CAN), Zyloprim cer chemotherapy has increased those levels and who can’t tolerate oral therapy allopurinol sodium I.V. INFUSION Aloprim Adults. 200 to 400 mg/m2 daily as a single infusion or in equally divided infusions Class and Category every 6, 8, or 12 hr. Maximum: 600 mg Chemical class: Hypoxanthine derivative, daily. xanthine oxidase inhibitor Children. 200 mg/m2 daily as a single infu- Therapeutic class: Antigout sion or in equally divided infusions every 6, Pregnancy category: C 8, or 12 hr. Indications and Dosages  To treat gout and hyperuricemia Route Onset Peak Duration TABLETS P.O. 2–3 days 1–3 wk* 1–2 wk Adults. 200 to 600 mg daily in divided doses, depending on disease severity. Usual: Mechanism of Action 200 to 300 mg daily. Maximum: 800 mg Inhibits uric acid production by inhibiting daily.  To treat secondary hyperuricemia * For hyperuricemia; several months for caused by neoplastic disease gout attack prevention.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 45 almotriptan malate 45 xanthine oxidase, the enzyme that converts CV: Vasculitis hypoxanthine and xanthine to uric acid. EENT: Epistaxis, loss of taste Allopurinol is metabolized to oxipurinol, GI: Abdominal pain, diarrhea, dysphagia, A which also inhibits xanthine oxidase. elevated liver function test results, gastritis, granulomatous hepatitis, hepatic necrosis, Incompatibilities hepatomegaly, nausea, vomiting Don’t combine I.V. allopurinol in solution GU: Exacerbated renal calculi, renal failure with amikacin, amphotericin B, carmustine, HEME: Agranulocytosis, aplastic anemia, cefotaxime sodium, chlorpromazine hydro- bone marrow depression, eosinophilia, chloride, cimetidine hydrochloride, clinda- leukocytosis, leukopenia, thrombocytopenia mycin phosphate, cytarabine, dacarbazine, MS: Arthralgia, exacerbation of gout, daunorubicin hydrochloride, diphenhydra- myopathy mine hydrochloride, doxorubicin SKIN: Alopecia; ecchymosis; jaundice; mac- hydrochloride, doxycycline hyclate, droperi- ulopapular, scaly, or exfoliative rash (some- dol, floxuridine, gentamicin sulfate, times fatal); pruritus; urticaria haloperidol lactate, hydroxyzine hydrochlo- ride, idarubicin hydrochloride, imipenem- Nursing Considerations cilastatin sodium, mechlorethamine • As ordered, obtain baseline CBC and uric hydrochloride, meperidine hydrochloride, acid level, and review results of renal and metoclopramide hydrochloride, methyl- liver function tests before and during allo- prednisolone sodium succinate, minocy- purinol therapy. cline hydrochloride, nalbuphine hydrochlo- • Reconstitute and dilute I.V. preparation to ride, netilmicin sulfate, ondansetron a concentration of 6 mg/ml or less. hydrochloride, prochlorperazine edisylate, WARNING Discontinue allopurinol and promethazine hydrochloride, sodium bicar- notify prescriber immediately at first sign bonate, streptozocin, tobramycin sulfate, of hypersensitivity reaction, such as rash, vinorelbine tartrate. which may precede more severe reactions. • To decrease risk of calculus formation, Contraindications maintain fluid intake of up to 3 L daily Hypersensitivity to allopurinol and monitor patient for output of 2 L Interactions daily. Also, don’t give vitamin C. DRUGS PATIENT TEACHING ACE inhibitors: Increased risk of hypersen- • Advise patient to take allopurinol after sitivity reactions meals and to drink at least 10 large glasses amoxicillin, ampicillin: Increased risk of rash of water daily. azathioprine, mercaptopurine: Inactivation • Instruct patient to report unusual bleeding of these drugs or bruising, fever, chills, gout attack, chlorpropamide: Increased risk of hypogly- numbness, and tingling. cemia in patients with renal insufficiency • Inform patient that acute gout attacks may cyclophosphamide, other cytotoxic drugs: occur more often early in allopurinol Enhanced bone marrow suppression treatment and that results may not be dicumarol: Increased half-life and anticoag- noticeable for 2 weeks or longer. ulant action of dicumarol • Instruct patient not to drive or perform thiazide diuretics: Possibly increased risk of hazardous tasks if drug causes drowsiness. allopurinol toxicity uricosuric agents: Increased urinary excre- tion of uric acid almotriptan malate vitamin C (large doses): Possibly urine acid- Axert ification and increased risk of renal calculus formation Class and Category Adverse Reactions Chemical class: Selective 5-hydroxytrypta- CNS: Chills, drowsiness, fever, headache, mine1 (5-HT1) receptor agonist neuritis, paresthesia, peripheral neuropathy, Therapeutic class: Antimigraine drug somnolence Pregnancy category: C
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 46 46 almotriptan malate Indications and Dosages EENT: Dry mouth  To treat acute migraine GI: Nausea TABLETS Other: Serotonin syndrome Adults and adolescents ages 12 to 17. Nursing Considerations Initial: 6.25 to 12.5 mg as a single dose, WARNING Because almotriptan can cause repeated in 2 hr p.r.n. Maximum: 2 doses/ coronary artery vasospasm, monitor 24 hr or 4 migraine treatments/mo. patient with CAD for angina. Because it DOSAGE ADJUSTMENT For patient with may cause peripheral vasospastic reactions, impaired renal or hepatic function, initial such as ischemic bowel disease, watch for dose reduced to 6.25 mg with maximum abdominal pain and bloody diarrhea. daily dose of 12.5 mg. • For patient with risk factors for CAD but Mechanism of Action no known cardiovascular abnormalities, May stimulate 5-HT1 receptors on intra- expect to give first dose of almotriptan in cranial blood vessels and sensory nerves in a medical facility. trigeminal vascular system. By activating • In patient with risk factors for CAD, these receptors, almotriptan selectively con- obtain an ECG immediately after first dose stricts inflamed and dilated cranial blood of almotriptan, as ordered, because cardiac vessels and inhibits production of proin- ischemia can occur without causing clini- flammatory neuropeptides. It also interrupts cal symptoms. transmission of pain signals to the brain. • Expect to give a lower dosage to patients with hepatic or renal dysfunction because Contraindications of impaired drug metabolism or excretion. Basilar or hemiplegic migraine; cerebro- • Monitor blood pressure regularly during vascular, peripheral vascular, or ischemic or therapy in patients with hypertension be- vasospastic coronary artery disease (CAD); cause almotriptan may produce a transient hypersensitivity to almotriptan or its com- increase in blood pressure. ponents; hypertension (uncontrolled); use WARNING Monitor patient for evidence of within 24 hours of other serotonin-receptor serotonin syndrome, such as agitation, agonists or ergotamine-containing or ergot- chills, confusion, diaphoresis, diarrhea, type drugs fever, hyperactive reflexes, poor coordina- Interactions tion, restlessness, shaking, talking or acting DRUGS with uncontrolled excitement, tremor, and ergotamine-containing drugs: Prolonged twitching. In its most severe form, sero- vasospastic reactions tonin syndrome can resemble neuroleptic erythromycin, itraconazole, ketoconazole, malignant syndrome, which includes a ritonavir: Possibly increased blood almo- high fever, muscle rigidity, autonomic triptan level instability with possible fluctuations in MAO inhibitors, verapamil: Increased blood vital signs, and mental status changes. almotriptan level • Monitor patients hypersensitive to sulfon- selective serotonin reuptake inhibitors, such amides for hypersensitivity to almotriptan as citalopram, escitalopram, fluoxetine, flu- because cross-sensitivity may occur. voxamine, paroxetine, sertraline: Increased PATIENT TEACHING risk of serotonin syndrome • Inform patient that almotriptan is used to serotonin norepinephrine reuptake inhibitors, treat acute migraine and that he shouldn’t such as duloxetine, venlafaxine: Increased take it to treat nonmigraine headaches. risk of serotonin syndrome • Advise patient to consult prescriber before taking any OTC or prescription drugs. Adverse Reactions • Advise patient not to take more than max- CNS: Dizziness, headache, paresthesia, imum prescribed. seizures, somnolence, syncope • Caution patient that drug may cause ad- CV: Coronary artery vasospasm, hyperten- verse CNS reactions, and advise him to sion, ischemia, MI, palpitations, vasodila- avoid hazardous activities until he knows tion, ventricular fibrillation, ventricular how drug affects him. tachycardia • Instruct patient to seek emergency care
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 47 alosetron hydrochloride 47 immediately for cardiac symptoms (such cimetidine, clarithromycin, itraconazole, pro- as heaviness, pain, pressure, or tightness in tease inhibitors, quinolones, telithromycin, chest, jaw, neck, or throat) or if multiple voriconazole: Possibly increased alosetron A new symptoms develop (such as mental level changes, high fever, incoordination, nau- sea, vomiting, diarrhea) after taking drug. Adverse Reactions CNS: Anxiety, fatigue, headache, hypnagog- ic effects, malaise, temperature regulation disturbances alosetron CV: Tachyarrhythmias hydrochloride GI: Abdominal or GI discomfort and pain, abdominal distention, constipation (may be Lotronex severe), diarrhea, dyspepsia, flatulence, GI spasms or lesions, hemorrhoids, hemor- Class and Category rhoidal hemorrhage, hyposalivation, ileus, Chemical class: Selective serotonin 5-HT3 impaction, ischemic colitis, nausea, receptor antagonist obstruction, perforation, regurgitation and Therapeutic class: Antidiarrheal reflux, small-bowel mesenteric ischemia, Pregnancy category: B ulceration Indications and Dosages GU: Urinary frequency  To treat women with severe diarrhea- RESP: Breathing disorders predominant irritable bowel syndrome SKIN: Diaphoresis, rash, urticaria (IBS) who haven’t responded to conven- Other: Nonspecific cramps or pain tional therapy Nursing Considerations TABLETS • Be aware that only physicians enrolled in Adults. Initial: 1 mg daily for 4 wk, GlaxoSmithKline’s prescribing program increased to 1 mg b.i.d. if needed. Dis- for alosetron should prescribe the drug continued if no response in first 4 wk of and only patients who have read and therapy or if drug doesn’t adequately con- signed the patient-physician agreement trol symptoms after 4 wk of b.i.d. regimen. can receive the drug. Confirm that the Mechanism of Action agreement has been signed before therapy Inhibits activation of 5-HT3 nonselective starts. cation channels found in enteric neurons in • Use alosetron cautiously in patients with the GI tract, thereby decreasing visceral mild to moderate liver dysfunction sensations, colonic transit, and secretions in because alosetron is extensively metabo- the GI tract. These changes reduce GI pain lized in the liver. and hyperactivity, symptoms that are • Report all adverse reactions to alosetron prominent in diarrhea-predominant IBS. to the prescriber and to Prometheus at 1-888-423-5227. Contraindications WARNING Monitor patient for constipation, Administration with fluvoxamine, history especially if she’s elderly or debilitated or of chronic or severe constipation or seque- takes drugs that decrease GI motility. Also lae from constipation, Crohn’s disease, watch for evidence of ischemic colitis, diverticulitis, GI perforation or adhesions, such as rectal bleeding, bloody diarrhea, or hypercoagulable state, impaired intestinal new or worsening abdominal pain. Serious circulation, intestinal obstruction or stric- adverse GI reactions may occur without ture, ischemic colitis, thrombophlebitis, warning. If they do, be prepared to stop toxic megacolon, or ulcerative colitis; alosetron therapy immediately. If discon- hypersensitivity to alosetron or its compo- tinued for ischemic colitis, drug shouldn’t nents; severe hepatic impairment be resumed later; however, a patient who Interactions no longer has constipation can resume it, DRUGS if needed. fluvoxamine, ketoconazole: Increased blood • Make sure program stickers required by alosetron level drug maker are affixed to all prescriptions,
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 48 48 alpha1-proteinase inhibitor (human) including refills, before giving to patient. proteinase products; selective immunoglob- PATIENT TEACHING ulin A (IgA) deficiency in patients with • Explain that alosetron therapy can’t begin anti-IgA antibodies until patient has read the medication Interactions guide that outlines drug’s risks and bene- ACTIVITIES fits and has signed the permission form. smoking: Inactivation of alpha1-proteinase • Instruct patient not to start alosetron if inhibitor constipated and to notify prescriber. • Advise patient that serious adverse GI Adverse Reactions effects may occur without warning. Tell CNS: Asthenia, chills, dizziness, fever, her to stop taking alosetron immediately headache, light-headedness, malaise, pares- and to notify prescriber if evidence of thesia ischemic colitis or constipation arises. Tell EENT: Sinusitis her to notify prescriber if constipation ENDO: Hot flashes doesn’t resolve after stopping drug. HEME: Mild, transient leukocytosis • Inform patient that alosetron will be RESP: Upper respiratory tract infection, stopped after 4 weeks of 1 mg b.i.d. if it worsening of existing COPD dosen’t control IBS symptoms. SKIN: Pruritus, rash Other: Flulike symptoms, infusion site pain Nursing Considerations alpha1-proteinase • Use alpha1-proteinase inhibitor cautiously in patients at risk for circulatory overload inhibitor (human) because drug is a colloid solution that Prolastin, Prolastin-C, Zemaira increases plasma volume. • Before reconstituting, remove drug and Class and Category diluent from refrigerator and let it warm Chemical class: Plasma protein to room temperature. Therapeutic class: Enzyme replacement • To reconstitute, remove caps from vials Pregnancy category: C and clean rubber stoppers with antiseptic. After stoppers are dry, remove protective Indications and Dosages cover from diluent end of transfer device  To treat congenital alpha1-antitrypsin and insert into center of upright diluent deficiency in patients with signs of vial. Then remove protective cover from panacinar emphysema (Prolastin); to drug end of transfer device, invert diluent augment and maintain patients with vial with attached transfer device, and emphysema who are deficient in alpha1- using minimal force, insert drug end of proteinase inhibitor transfer device into center of rubber stop- I.V. INFUSION per of upright drug vial. Make sure flange Adults. 60 mg/kg infused over 30 min of transfer device rests on stopper surface (Prolastin) or 15 min (Prolastin-C, so that diluent flows into drug vial. Zemaira) at a rate of at least 0.08 ml/kg/ • During diluent transfer, wet lyophilized min once weekly. cake completely by gently tilting drug vial. Don’t let air inlet filter face downward. Mechanism of Action (Take care not to lose the vacuum because Replaces the enzyme alpha1-antitrypsin, this will prolong drug reconstitution.) which normally inhibits the proteolytic Once diluent transfer is complete, pull enzyme elastase in patients with alpha1- transfer device along with attached diluent antitrypsin deficiency. Without alpha1- vial out of drug vial and discard. Gently proteinase inhibitor, elastase attacks and swirl drug vial until powder is completely destroys alveolar membranes and causes dissolved. Avoid shaking because this may emphysema. cause drug to foam and degrade. Contraindications • If more than one vial of alpha1-proteinase Hypersensitivity to alpha1-proteinase inhibitor is required, use aseptic technique inhibitor, its components, or other alpha1- to transfer reconstituted solution from
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 49 alprazolam 49 each vial into a sterile I.V. administration TABLETS container. Adults. Initial: 0.25 to 0.5 mg t.i.d., adjust- • Administer at room temperature within A ed to patient’s needs. Maximum: 4 mg daily 3 hours of reconstitution as an I.V. infu- in divided doses. sion, using the large-volume 5-micron DOSAGE ADJUSTMENT In elderly or debilitat- conical filter provided. Place filter between ed patients or patients with advanced distal end of I.V. administration set and hepatic disease, initial dosage 0.25 mg b.i.d. infusion set, and infuse at 0.08 ml/kg/min or t.i.d. and increased gradually, as needed or as determined by patient response and and tolerated. comfort.  To treat panic attack WARNING Alpha1-proteinase inhibitor is ORALLY DISINTEGRATING TABLETS, TABLETS made from human plasma and may con- Adults. Initial: 0.5 mg t.i.d., increased every tain infectious agents, such as viruses. 3 to 4 days by no more than 1 mg daily, Make sure patient is immunized against based on patient response. Maximum: hepatitis B before giving drug. If time 10 mg daily in divided doses. doesn’t allow for antibody formation, give E.R. TABLETS a single dose of hepatitis B immune glob- Adults. Initial: 0.5 to 1 mg daily in morn- ulin with hepatitis B vaccine, as pre- ing, increased every 3 to 4 days by no more scribed. than 1 mg daily, based on patient response. • Monitor patient for delayed fever, which Maximum: 10 mg daily as single dose in may occur up to 12 hours after therapy. morning. Fever usually resolves within 24 hours. Mechanism of Action PATIENT TEACHING May increase effects of gamma-aminobu- • Tell patient to report immediately early tyric acid (GABA) and other inhibitory evidence of allergic reaction, such as chest neurotransmitters by binding to specific tightness, trouble breathing, faintness, benzodiazepine receptors in limbic and cor- hives, wheezing, and any other unusual tical areas of the CNS. GABA inhibits exci- symptoms. tatory stimulation, which helps control • Advise patient to notify prescriber about emotional behavior. The limbic system con- signs or symptoms of viral infection tains many benzodiazepine receptors, which (chills, drowsiness, fever, and runny nose, may help explain drug’s antianxiety effects. followed 2 weeks later by joint pain and a rash) after receiving drug. Contraindications • Stress importance of receiving weekly Acute angle-closure glaucoma; hypersensi- doses to maintain an adequate antielastase tivity to alprazolam, its components, or barrier in the lungs. Explain that treat- other benzodiazepines; itraconazole or ment must continue for life. ketoconazole therapy • Warn patient not to smoke. Interactions DRUGS antacids: Altered alprazolam absorption rate alprazolam cimetidine, disulfiram, fluoxetine, isoniazid, Apo-Alpraz (CAN), Novo-Alprazol metoprolol, oral contraceptives, propoxyphene, (CAN), Nu-Alpraz, Xanax, Xanax XR propranolol, valproic acid: Decreased alpra- zolam elimination and increased effects CNS depressants: Possibly increased CNS Class, Category, and Schedule effects of both drugs Chemical class: Benzodiazepine digoxin: Possibly increased serum digoxin Therapeutic class: Antianxiety drug level, causing digitalis toxicity Pregnancy category: D itraconazole, ketoconazole: Possibly pro- Controlled substance schedule: IV foundly inhibited alprazolam metabolism Indications and Dosages levodopa: Decreased effects of levodopa  To control anxiety disorders, relieve anx- neuromuscular blockers: Possibly potentiated iety (short-term therapy), or treat anxi- or antagonized effects of these drugs ety associated with depression phenytoin: Possibly increased serum pheny-
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 50 50 alprostadil toin level, causing phenytoin toxicity to notify prescriber immediately if she probenecid: Possibly faster onset or pro- becomes or might be pregnant. Drug isn’t longed effects of alprazolam recommended during pregnancy. ranitidine: Possibly reduced absorption of alprazolam ACTIVITIES alprostadil alcohol use: Enhanced adverse CNS effects of alprazolam Caverject, Edex, Muse Adverse Reactions Class and Category CNS: Agitation, akathisia, confusion, Chemical class: Prostaglandin E1 depression, dizziness, drowsiness, fatigue, Therapeutic class: Anti-impotence drug hallucinations, headache, insomnia, irri- Pregnancy category: C tability, lack of coordination, light- headedness, memory loss, nervousness, Indications and Dosages paresthesia, rigidity, speech problems, syn-  To treat erectile dysfunction caused by cope, tremor, weakness vascular or psychogenic causes or both CV: Chest pain, edema, hypotension, non- INTRACAVERNOUS INJECTION (CAVERJECT, EDEX) specific ECG changes, palpitations, tachy- Adults. Initial: 2.5 mcg. Increased to 5 mcg cardia if partial response or 7.5 mcg if no EENT: Blurred vision, altered salivation, dry response, followed by incremental increases mouth, nasal congestion, tinnitus of 5 to 10 mcg until erection suitable for ENDO: Galactorrhea, gynecomastia, hyper- intercourse (not exceeding 1-hr duration) is prolactinemia achieved. No more than 2 doses, separated GI: Abdominal discomfort, anorexia, con- by 1 hr, should be given on a single day stipation, diarrhea, elevated liver function during initial titration phase. Maximum: test results, hepatitis, hepatic failure, nau- 3 doses/wk, separated by 24 hr. sea, vomiting URETHRAL SUPPOSITORY (MUSE) GU: Altered libido, urinary hesitancy Adults. Initial: 125 to 250 mcg. If no MS: Dysarthria, muscle rigidity and spasms response, dosage increased in increments to RESP: Hyperventilation, upper respiratory 500 or 1,000 mcg until erection suitable for tract infection intercourse (not exceeding 1-hr duration) is SKIN: Dermatitis, diaphoresis, pruritus, achieved. Maximum: 2 doses/24 hr. rash, Stevens-Johnson syndrome  To treat erectile dysfunction caused by Other: Weight gain or loss spinal cord injury INTRACAVERNOUS INJECTION (CAVERJECT, EDEX) Nursing Considerations Adults. Initial: 1.25 mcg. Increased to • Expect to give a higher dosage if patient’s 2.5 mcg if partial response, then to 5 mcg, panic attacks occur unexpectedly or dur- and increased in 5-mcg increments until ing such activities as driving. erection suitable for intercourse (not • Because use can lead to dependency, exceeding 1-hr duration) is achieved. No expect to reduce dosage gradually when more than 2 doses, separated by 1 hr, stopping drug. To prevent withdrawal should be given on a single day during ini- symptoms, don’t stop drug abruptly. tial titration phase. Maximum: 3 doses/ PATIENT TEACHING week, separated by 24 hr. • Warn against stopping drug abruptly because withdrawal symptoms may occur. Route Onset Peak Duration • Instruct patient never to increase pre- scribed dose because of risk of dependency. Intra- 5–20 min Unknown 60 min • Urge patient to avoid drinking alcohol cavernous during alprazolam therapy. Intra- 5–10 min Unknown 30–60 min • Advise patient to avoid driving and activi- urethral ties that require alertness until alprazo- lam’s effects are known. Contraindications • Instruct female patient of childbearing age Anuria, balanitis (inflammation of head of
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 51 alprostadil 51 Mechanism of Action Alprostadil causes penile erection by Dorsal veins Dorsal artery A Adeny increasing blood flow to the penis cyclas Trabecular through relaxation of trabecular smooth smooth Outside corpus muscles and dilation of cavernosal arter- muscles cavernosum cell ies (upper right). A naturally occurring prostaglandin, alprostadil interacts with specific membrane-bound receptors in Corpus the corpora cavernosa cells of the penis. cavernosum This action activates intracellular adenyl Lacunar space Urethra cyclase (lower right), which in turn con- ATP verts adenosine triphosphate (ATP) into Transverse section of penis Inside corpus cavern cyclic adenosine monophosphate (cAMP). Increased intracellular levels of cAMP activate protein kinase, an enzyme Dorsal veins Dorsal artery Alprostadil Adenyl that activates other enzymes to initiate a cyclase cascade of chemical reactions. Trabecular Receptor smooth chemical reactions cause the Outside corpus These cavernosum cell muscles trabecular smooth muscles to relax and the cavernosal arteries to dilate. Blood flow to the penis is then increased, which Corpus distends the penile lacunar spaces and cavernosum Protein compresses the veins, trapping blood in kinase the penis and space it Urethra Lacunar causing to become ATP cAMP enlarged and rigid. Transverse section of penis Inside corpus cavernosum cell penis), cavernosal fibrosis, hypersensitivity edema, fibrosis, pain, and rash; priapism; to alprostadil or its components, hypervis- prolonged erection; prostatic pain or cosity syndrome, indwelling urethral enlargement; urethral abrasions; urethral catheter, leukemia, men for whom sexual bleeding activity is contraindicated, multiple myelo- MS: Back pain ma, penile angulation, penile implants, RESP: Cough, upper respiratory tract infec- Peyronie’s disease, polycythemia, severe tion hypospadius (urethral opening on under- Other: Flulike symptoms, injection site side of penis), sickle cell anemia or trait, bruising or hematoma, needle breakage tendency to develop venous thrombosis, Nursing Considerations thrombocythemia, urethral obstruction or • Reconstitute solution with 1 ml diluent, stricture, urethritis for a concentration of 5, 10, 20, or 40 mcg/ Interactions ml, depending on vial strength. Gently DRUGS swirl contents of reconstituted vial. Use anticoagulants: Possibly increased risk of reconstituted solution within 24 hours bleeding when stored at room temperature. Don’t cyclosporine: Possibly decreased blood use vials that contain precipitate or discol- cyclosporine level ored solution. Discard unused reconstitut- ed solution. Adverse Reactions • Using a 1⁄2-inch 27G to 30G needle, inject CNS: Dizziness, headache, syncope drug at a 90-degree angle into proximal CV: Hypertension, hypotension, tachycar- third of spongy tissue that runs the length dia, vasodilation of the dorsolateral aspect of penis, avoid- EENT: Nasal congestion, sinusitis ing any visible veins. Rotate injection sites GU: Pelvic pain; penile disorders, including by alternating sides of the penis.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 52 52 alteplase • Carefully examine penis for evidence of increase blood flow and enhance erection. penile fibrosis. Expect to discontinue • Tell patient to expect an erection 5 to treatment if patient develops cavernosal 20 minutes after injecting drug or about fibrosis, penile angulation, or Peyronie’s 10 minutes after inserting suppository. disease (hardening of the corpora caver- • Advise patient not to change dosage with- nosa, which causes penis to become dis- out consulting prescriber and to keep torted when erect) during therapy. scheduled follow-up appointments. WARNING Watch for prolonged erection • Warn patient that alprostadil offers no after giving drug. Notify prescriber, and be protection from sexually transmitted dis- prepared to treat patient for priapism if eases. Urge him to use a condom to erection lasts longer than 4 hours. decrease risk of blood-borne disease, • If patient is receiving an anticoagulant, because injection can cause minor bleed- such as warfarin or heparin, watch for ing at injection site. bleeding at injection site because drug • Instruct patient not to reuse or share nee- may inhibit platelet aggregation. dles or syringes. Inform him of proper PATIENT TEACHING procedure for sharps disposal. • Inform patient that initial therapy must be • Warn patient using suppository form not performed in the office setting. Teach him to have sexual intercourse with a pregnant how to correctly administer intracav- woman unless a condom is used because ernous injections or urethral supposito- drug’s effect on pregnancy is unknown. ries. Inform him that the goal of treatment • Advise patient who plans to travel not to is to produce an erection that lasts no check drug with airline baggage or store it longer than 1 hour. in a closed car. • Advise patient to use alprostadil for injec- tion no more than three times/week and to separate doses by 24 hours. Inform alteplase patient using urethral suppositories not to exceed two doses in a 24-hour period. (tissue plasminogen • Tell patient to inform prescriber immedi- activator, recombinant) ately about nodules or hard tissue in the Activase, Activase rt-PA (CAN) penis; an erection that persists for more than 4 hours; new or worsened penile pain; or persistent curvature, redness, Class and Category Chemical class: Purified glycoprotein swelling, or tenderness of the erect penis. Therapeutic class: Thrombolytic • Inform patient that common adverse reac- Pregnancy category: C tions include mild to moderate pain immediately after injection and burning Indications and Dosages after suppository insertion. Also, needle  To treat acute MI may break. Advise patient to avoid it by ACCELERATED I.V. INFUSION following prescriber’s instructions exactly Adults weighing more than 67 kg (148 lb). and by handling injection device properly. 15-mg bolus followed by 50 mg infused If needle breaks during injection and he over next 30 min and then by 35 mg can see and grasp broken end, he should infused over next 60 min. remove it and contact prescriber. If he Adults weighing 67 kg or less. 15-mg bolus can’t see or grasp broken end, he should followed by 0.75 mg/kg (up to 50 mg) seek medical care. infused over next 30 min and then 0.5 mg/ • Instruct patient using suppository form to kg (up to 35 mg) infused over next 60 min. urinate just before inserting suppository I.V. INFUSION and to insert it with applicator supplied Adults weighing more than 65 kg (143 lb). with drug. Tell patient to hold penis 100 mg infused over 3 hr as follows: 6 to upright after insertion and to roll it firmly 10 mg by bolus over first 1 to 2 min, 50 to between his hands to distribute drug. 54 mg over remainder of first hr, 20 mg • Tell patient to sit, stand, or walk for 10 over second hr, and 20 mg over third hr. minutes after inserting suppository to Adults weighing 65 kg or less. 1.25 mg/kg
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 53 alteplase 53 infused over 3 hr on similar schedule as CV: Arrhythmias (including bradycardia those weighing more than 65 kg. and electromechanical dissociation), car-  To treat acute ischemic stroke diac arrest, cardiac tamponade, cardiogenic A To avoid acute bleeding complications, shock, cholesterol embolism, coronary treatment for acute ischemic stroke must thrombolysis, heart failure, hypotension, begin within 3 hr after onset of stroke mitral insufficiency, myocardial reinfarction symptoms and only after computed tomog- or rupture, pericardial effusion, pericarditis, raphy or other diagnostic imaging method venous thrombosis and embolism excludes intracranial hemorrhage. EENT: Epistaxis, gingival bleeding, laryn- I.V. INFUSION geal edema Adults. 0.9 mg/kg infused over 60 min, GI: GI bleeding, nausea, retroperitoneal with 10% of total dose given as bolus over bleeding, vomiting first min. Maximum: 90 mg. GU: GU bleeding  To treat pulmonary embolism RESP: Pleural effusion, pulmonary edema, I.V. INFUSION pulmonary reembolization Adults. 100 mg infused over 2 hr. SKIN: Bleeding at puncture sites, ecchymo- sis, rash, urticaria Route Onset Peak Duration Other: Anaphylaxis I.V. Immediate 20–120 min 4 hr Nursing Considerations WARNING To avoid acute bleeding compli- Mechanism of Action cations, treatment for acute ischemic Binds to fibrin in a thrombus and converts stroke must begin within 3 hr after onset trapped plasminogen to plasmin. Plasmin of stroke symptoms and only after com- breaks down fibrin, fibrinogen, and other puted tomography or other diagnostic clotting factors, which dissolves the throm- imaging method excludes intracranial bus. hemorrhage. Incompatibilities • Immediately before use, reconstitute alte- Don’t add other drugs to solution that con- plase with sterile water for injection only. tains alteplase. Swirl gently to dissolve powder; don’t shake. Contraindications • Monitor patient for bleeding, especially at For all indications: Active internal bleeding, arterial puncture sites. arteriovenous malformation or aneurysm, • Monitor blood pressure and heart rate and bleeding diathesis, intracranial neoplasm, rhythm frequently during and after thera- severe uncontrolled hypertension py. For acute MI and pulmonary embolism only: WARNING Alteplase therapy may cause History of stroke, intracranial or intraspinal arrhythmias from sudden reperfusion of surgery or trauma in past 2 months the myocardium. Monitor continuous For acute ischemic stroke only: Recent head ECG for arrhythmias during drug therapy. trauma, recent intracranial surgery, recent • Minimize bleeding from noncompressible stroke, seizure activity at onset of stroke, sites by avoiding internal jugular and sub- subarachnoid hemorrhage, suspicion or clavian venous puncture sites. history of intracranial hemorrhage • Discontinue alteplase immediately if seri- ous bleeding occurs. Interactions • After administering alteplase, apply pres- DRUGS sure for at least 30 minutes, followed by a drugs that alter platelet function, such as pressure dressing. abciximab, acetylsalicylic acid, and dipyrida- • Store reconstituted solution at room tem- mole; heparin; vitamin K antagonists: perature (about 86° F [30° C]) or refriger- Increased risk of bleeding ated (36° to 46° F [2.2° to 7.7° C]). Adverse Reactions PATIENT TEACHING CNS: Cerebral edema, cerebral herniation, • Tell patient to immediately report bleed- fever, seizure, stroke ing, including from the nose or gums.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 54 54 aluminum; alvimopan • Advise patient to limit physical activity Contraindications during alteplase administration to reduce Hypersensitivity to aluminum risk of injury and bleeding. Interactions DRUGS allopurinol, chloroquine, corticosteroids, aluminum diflunisal, digoxin, ethambutol, H2-receptor carbonate blockers, iron, isoniazid, penicillamine, phenothiazines, ranitidine, tetracyclines, thy- Basaljel roid hormones, ticlopidine: Decreased effects of these drugs aluminum benzodiazepines: Increased benzodiazepine hydroxide effects AlternaGEL, Alu-Cap, Alugel (CAN), Adverse Reactions Alu-Tab, Amphojel, Dialume CNS: Encephalopathy GI: Constipation, intestinal obstruction, Class and Category white-speckled stool Chemical: Aluminum salt MS: Osteomalacia, osteoporosis Therapeutic: Antacid, phosphate binder Other: Aluminum accumulation in serum, Pregnancy category: Not rated bone, and CNS; aluminum intoxication; electrolyte imbalances Indications and Dosages  To treat hyperacidity associated with Nursing Considerations gastric hyperacidity, gastritis, hiatal her- • Don’t give aluminum hydroxide within nia, peptic esophagitis, and peptic ulcers; 1 to 2 hours of other oral drugs. to prevent phosphate renal calculus for- • Know that two 0.6-g aluminum hydroxide mation; to reduce hyperphosphatemia in tablets can neutralize 16 mEq of acid. chronic renal failure • Monitor patient’s serum levels of sodium, ALUMINUM CARBONATE CAPSULES, SUSPENSION, phosphate, and other electrolytes, as TABLETS appropriate. Adults. 2 capsules or tablets or 10 ml sus- PATIENT TEACHING pension every 2 hr up to 12 times daily p.r.n. • Instruct patient to chew tablets thoroughly ALUMINUM HYDROXIDE CAPSULES, SUSPENSION, before swallowing and then to drink a full TABLETS glass of water. Adults. 500 to 1,500 mg as capsules or • Warn patient not to take maximum tablets in divided doses 3 to 6 times daily, dosage for more than 2 weeks unless pre- taken between meals and at bedtime; 5 to scribed because doing so may cause stom- 30 ml as suspension, p.r.n., taken between ach to secrete excess hydrochloric acid. meals and at bedtime. • Teach patient to prevent constipation with a high-fiber diet and increased fluid intake Route Onset Peak Duration (2 to 3 L daily), if appropriate. • If patient takes other prescription drugs, P.O. Varies Unknown 20–40 min* advise him to notify prescriber about thembefore taking aluminum because of Mechanism of Action risk of interactions. Neutralizes or reduces gastric acidity, • Advise patient to notify prescriber if increasing stomach and duodenal alkalinity. symptoms worsen or don’t subside. Protects stomach and duodenum lining by inhibiting pepsin’s proteolytic activity. Binds with phosphate ions in intestine to form insoluble aluminum-phosphate com- alvimopan pounds, which lower blood phosphate level. Entereg * If fasting; at least 3 hr if given 1 hr after Class and Category meals. Chemical class: Single stereoisomer
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 55 amantadine hydrochloride 55 Therapeutic class: Mu opioid receptor term use with maximum of 15 doses and antagonist is only dispensed in hospitals enrolled in Pregnancy category: B Entereg Access Support and Education A (E.A.S.E.) program. Closely monitor num- Indications and Dosages  To accelerate GI recovery in hospitalized ber of doses given, and expect to stop drug when patient has received 15 doses or is patients after partial large- or small- discharged from hospital. bowel resection with primary anastomosis • Monitor patient’s serum potassium level CAPSULES closely, as ordered, because drug may Adults. Initial: 12 mg started 30 min to 5 hr cause hypokalemia. Also check patient’s before surgery, followed by 12 mg b.i.d. hemoglobin level and hematocrit because starting the day after surgery for up to 7 drug has been associated with anemia. days or until discharge. Maximum: 24 mg/ • Monitor patient with mild to moderate day with a maximum of 15 doses total. hepatic or renal failure for evidence of high alvimopan levels, such as abdominal Route Onset Peak Duration pain or cramping, diarrhea, nausea, and P.O. Unknown 2 hr Unknown vomiting. If present, alert prescriber. • Monitor Japanese patients closely for pos- Mechanism of Action sible adverse effects because alvimopan Competitively binds to selective mu opioid level may be higher in this population. receptors in GI tract, antagonizing periph- PATIENT TEACHING eral effects of opioids on GI motility and • Explain the need to accurately describe secretion without reversing the central long-term or intermittent use of opioid analgesic effects of opioid agonists. This pain therapy, including any use of opioids action alleviates postoperative ileus by caus- in the week before receiving alvimopan. ing bowel function to return more quickly Taking almivopan after such use may after part of bowel has been removed and cause serious adverse GI reactions. an end-to-end anastomosis performed. • Inform patient that the most common Contraindications adverse effects of alvimopan are constipa- Hypersensitivity to alvimopan or its com- tion, dyspepsia, and flatulence. ponents, severe hepatic or renal impair- • Tell patient that drug is for in-hospital use ment, use of opiods for more than 7 con- only and will not be taken at home. secutive days immediately before alvimopan starts amantadine Interactions DRUGS hydrochloride opioids given within previous 7 days at thera- peutic doses: Increased sensitivity to alvi- (adamantanamine mopan hydrochloride) Adverse Reactions Endantadine (CAN), Gen-Amantadine GI: Abdominal pain, constipation, diarrhea, (CAN), Symmetrel dyspepsia, flatulence GU: Urine retention Class and Category HEME: Anemia Chemical class: Adamantane derivative MS: Back pain Therapeutic class: Antidyskinetic, antiviral Other: Hypokalemia Pregnancy category: C Nursing Considerations Indications and Dosages • Don’t give alvimopan to patients with  To manage symptoms of primary severe hepatic or renal impairment or to Parkinson’s disease, postencephalitic patients having surgery to correct a com- parkinsonism, arteriosclerotic parkin- plete bowel obstruction. sonism, and parkinsonism caused by • Alvimopan is prescribed only for short- CNS injury from carbon monoxide
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 56 56 amantadine hydrochloride intoxication ing from substantia nigra to basal ganglia CAPSULES, SYRUP, TABLETS and is essential for normal motor function. Adults. Initial: 100 mg b.i.d. Maximum: In Parkinson’s disease, progressive degener- 400 mg daily in divided doses. ation of these neurons reduces intrasynap-  To treat drug-induced extrapyramidal tic dopamine. Amantadine may cause reactions dopamine to accumulate in the basal gan- CAPSULES, SYRUP, TABLETS glia by increasing dopamine release or by Adults. Initial: 100 mg b.i.d. Maximum: blocking dopamine reuptake into the presy- 300 mg daily in divided doses. naptic neurons of the CNS. Amantadine DOSAGE ADJUSTMENT For elderly patients, also may stimulate dopamine receptors or patients taking high doses of other antidys- make postsynaptic receptors more sensitive kinetics, and patients who have a serious to dopamine. These actions help control medical condition (such as heart failure, alterations in involuntary muscle move- epilepsy, or psychosis), initial dosage ments, such as tremors and rigidity, that are reduced to 100 mg daily, with gradual titra- associated with Parkinson’s disease. tion to 100 mg b.i.d. after 1 to several wk. Amantadine may inhibit influenza A For patients with impaired renal function, viral replication by blocking uncoating of dosage adjusted to 200 mg on day 1 and virus and release of viral nucleic acid into then to 100 mg daily if creatinine clearance respiratory epithelial cells. It also may inter- is 30 to 50 ml/min/1.73 m2; to 200 mg on fere with early replication of viruses that day 1 and then to 100 mg every other day if have already penetrated cells. creatinine clearance is 15 to 29 ml/min/ Contraindications 1.73 m2; and to 200 mg every wk if creati- Angle-closure glaucoma, hypersensitivity to nine clearance is less than 15 ml/min/1.73 amantadine or its components m2 or if patient is receiving hemodialysis.  To prevent and treat respiratory tract Interactions infection caused by influenza A DRUGS CAPSULES, SYRUP, TABLETS anticholinergics or other drugs with anti- Adults and children age 12 and over. cholinergic activity, other antidyskinetics, Initial: 200 mg daily or 100 mg b.i.d. antihistamines, phenothiazines, tricyclic Maximum: 200 mg daily. antidepressants: Possibly increased anticho- DOSAGE ADJUSTMENT In impaired renal linergic effects and risk of paralytic ileus function, if creatinine clearance is 30 to carbidopa-levodopa, levodopa: Increased 50 ml/min/1.73 m2, 200 mg on day 1 and effectiveness of these drugs then 100 mg daily. If clearance is 15 to CNS stimulants: Excessive CNS stimulation, 29 ml/min/1.73 m2, 200 mg on day 1 and possibly causing arrhythmias, insomnia, then 100 mg every other day. If clearance is irritability, nervousness, or seizures less than 15 ml/min/1.73 m2 or patient is hydrochlorothiazide, triamterene: Possibly having hemodialysis, 200 mg every wk. decreased amantadine clearance and Children ages 9 to 12. 100 mg every 12 hr. increased risk of toxicity Maximum: 200 mg daily. live-virus vaccines: Possibly interference Children ages 1 to 9. 1.5 to 3 mg/kg every with vaccine effectiveness 8 hr or 2.2 to 4.4 mg/kg every 12 hr. quinidine, quinine, trimethoprim- Maximum: 150 mg/day. sulfamethoxazole: Increased blood amanta- dine level Route Onset Peak Duration ACTIVITIES P.O. In 48 hr* Unknown Unknown alcohol use: Possibly increased risk of CNS effects—including confusion, dizziness, and Mechanism of Action light-headedness—and orthostatic Affects dopamine, a neurotransmitter that hypotension is synthesized and released by neurons lead- Adverse Reactions CNS: Agitation, anxiety, confusion, dizzi- * Antidyskinetic action; antiviral action ness, drowsiness, fatigue, fever, hallucina- unknown. tions, insomnia, irritability, light-headed-
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 57 amantadine hydrochloride 57 ness, mental impairment, nervousness, neu- dosage reduction or discontinuation of roleptic malignant syndrome, nightmares, therapy. These include fever, hypertension suicidal ideation, syncope or hypotension, involuntary motor activi- A CV: Arrhythmias, cardiac arrest, orthostatic ty, mental changes, muscle rigidity, tachy- hypotension, peripheral edema, tachycardia cardia, and tachypnea. Be prepared to pro- EENT: Blurred vision; dry mouth, nose, or vide supportive treatment and additional throat; keratitis; mydriasis drug therapy, as prescribed. GI: Constipation, diarrhea, dysphagia, • Be aware that patients receiving more than nausea 200 mg daily are more likely to experience GU: Dysuria, increased libido adverse or toxic reactions. HEME: Agranulocytosis, leukopenia, neu- • Monitor patient for decreased drug effec- tropenia tiveness over time. If therapeutic response RESP: Acute respiratory failure, pulmonary declines, expect to increase dosage or dis- edema, tachypnea continue drug temporarily, as ordered. SKIN: Diaphoresis, livedo reticularis (pur- • Assess patient regularly for skin changes plish, netlike rash), pruritus because melanoma risk is higher in those Other: Anaphylaxis; intense urges to per- with Parkinson’s disease. It isn’t clear form certain activities, such as gambling or whether the risk is increased by the disease sexual acts or by its treatment. PATIENT TEACHING Nursing Considerations • Instruct patient to take amantadine exactly • Be aware that prophylactic therapy with as prescribed and not to stop abruptly. amantadine should begin as soon as possi- Advise patient to notify prescriber if drug ble after exposure to persons infected with becomes less effective. influenza A virus and should continue for • Tell patient to notify prescriber if influenza 10 days. During an influenza epidemic, symptoms don’t improve after 2 to 3 days. expect drug to be given daily throughout WARNING Advise patient or family member the epidemic, which typically lasts 6 to 8 to notify prescriber immediately if patient weeks. If patient has previously received reveals thoughts of suicide. inactivated influenza A vaccine, prescriber • Encourage patient to avoid consuming may discontinue it when sure that patient alcohol during amantadine therapy has developed active immunity against the because alcohol may increase the risk of virus. If patient receives inactivated confusion, dizziness, light-headedness, or influenza A vaccine at the same time orthostatic hypotension. amantadine therapy starts, expect amanta- • Advise patient to avoid driving and other dine to be given for 2 to 3 weeks. activities that require a high level of alert- • Expect amantadine therapy to start 24 to ness until he knows how the drug affects 48 hours after the onset of influenza A him because it may cause blurred vision symptoms and to continue 48 hours after and mental impairment. they resolve. • Advise patient to change positions slowly • Monitor patients who have a history of to minimize effects of orthostatic psychiatric illness or substance abuse hypotension. because amantadine may worsen these • Tell patient to use ice chips or sugarless conditions. Some patients taking amanta- candy or gum to relieve dry mouth. dine have attempted suicide or had suici- • Caution patient to resume physical activi- dal ideation. ties gradually as signs and symptoms • If patient has a history of heart failure or improve. peripheral edema, monitor for weight gain • Urge patient to have regular skin examina- and edema because drug may cause redis- tions by a dermatologist or other qualified tribution of body fluid. health professional. • Amantadine may increase seizure activity • Instruct patient to notify prescriber about in patients with a history of seizures. intense urges, such as for gambling or sex, WARNING Monitor patient for evidence of because dosage may need to be reduced or neuroleptic malignant syndrome during drug discontinued.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 58 58 ambenonium chloride Adverse Reactions CNS: Dizziness, drowsiness, headache, loss ambenonium of consciousness, seizures, syncope chloride CV: AV block, bradycardia, decreased car- diac output, hypotension Mytelase EENT: Dysphonia, increased salivation, laryngospasm Class and Category GI: Abdominal cramps, dysphagia, flatu- Chemical class: Synthetic quaternary lence, increased gastric and intestinal secre- ammonium compound tions, increased peristalsis, mild diarrhea, Therapeutic class: Antimyasthenic, cholinergic nausea, vomiting Pregnancy category: C GU: Incontinence, urinary frequency or urgency Indications and Dosages MS: Arthralgia, dysarthria, fasciculations,  To improve muscle strength in patients muscle spasms, muscle weakness with myasthenia gravis in whom pyri- RESP: Bronchoconstriction, bronchospasm, dostigmine or neostigmine are con- dyspnea, increased tracheobronchial secre- traindicated tions, lung congestion, respiratory arrest or TABLETS depression, respiratory muscle paralysis Adults and adolescents. Initial: 5 mg t.i.d. SKIN: Diaphoresis, flushing, rash, urticaria or q.i.d., increased at 1- to 2-day intervals to optimum dosage based on patient Nursing Considerations response. Usual: Highly individualized but • Increase dosage gradually as prescribed to usually 5 to 50 mg t.i.d. or q.i.d. avoid ambenonium buildup and overdose. Children. Initial: 0.3 mg/kg or 10 mg/m2 • When increasing dosage to optimum level, daily in divided doses t.i.d. or q.i.d. note when no further increase in muscle Maintenance: Up to 1.5 mg/kg or 50 mg/m2 strength is observed. Then expect to daily in divided doses t.i.d. or q.i.d. reduce dosage to previous effective level and to use this as maintenance dosage. Route Onset Peak Duration • Expect prescriber to order ephedrine (25 mg per ambenonium dose) or potassi- P.O. 20–30 min Unknown 3–8 hr um chloride (1 to 2 g per ambenonium dose) to further improve muscle strength. Mechanism of Action WARNING Drug has a narrow margin Attaches to acetylcholinesterase and blocks between effectiveness and overdose. If its breakdown. This action prolongs and patient receives more than 200 mg daily, exaggerates acetylcholine’s effects, produc- watch closely for overdose (cholinergic ing cholinergic responses, such as miosis, crisis), such as abdominal cramps, diar- increased intestinal and skeletal muscle rhea, nausea, vomiting, increased saliva- tone, bronchoconstriction, bradycardia, and tion, diaphoresis, difficulty swallowing, increased salivary and sweat gland secretion. blurred vision, miosis, hypertension, fasci- Contraindications culations, and voluntary muscle paralysis. Hypersensitivity to ambenonium, its com- • Assess neuromuscular status to detect pro- ponents, or anticholinesterases; mechanical gressive or recurrent muscle weakness intestinal or urinary tract obstruction during long-term ambenonium therapy. • If patient develops drug resistance in long- Interactions term therapy, expect to restore responsive- DRUGS ness by decreasing dosage or briefly stop- anesthetics, antiarrhythmics, corticos- ping drug with close supervision. teroids, magnesium, methocarbamol: PATIENT TEACHING Decreased effects of ambenonium • Instruct patient to swallow tablet with liq- aminoglycosides, anticholinesterase muscle uid or food to minimize GI irritation. stimulants, depolarizing muscle relaxants, • Advise patient to consult prescriber before ganglionic blockers, mecamylamine: discontinuing drug—even if symptoms Increased effects of ambenonium diminish or disappear.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 59 ambrisentan 59 Adverse Reactions CNS: Headache ambrisentan CV: Heart failure, palpitations, peripheral A Letairis edema EENT: Nasal congestion, nasopharyngitis, Class and Category sinusitis Chemical class: Autocrine and paracrine GI: Abdominal pain, constipation, elevated peptide liver enzymes Therapeutic class: Endothelin receptor HEME: Anemia antagonist RESP: Dyspnea Pregnancy category: X SKIN: Flushing Other: Angioedema Indications and Dosages  To treat pulmonary arterial hyperten- Nursing Considerations sion, improve exercise capacity, and • Ambrisentan isn’t recommended for delay worsening in patients with World patients with moderate to severe hepatic Health Organization (WHO) class II or impairment. Use it cautiously in patients III symptoms with mild hepatic impairment. TABLETS • Ambrisentan is available only through a Adults. Initial: 5 mg once daily, increased to restricted distribution program. Patients 10 mg once daily as needed and tolerated. must be enrolled, meet all conditions of the program, and be re-enrolled annually. • Before giving ambrisentan for the first Route Onset Peak Duration time, make sure patient understands its P.O. Unknown 2 hr Unknown risks, has signed the agreement form, and knows that he’ll need to be re-enrolled Mechanism of Action after 6 months of therapy and then yearly. Blocks the action of endothelin-1 (ET-1), a • If patient is a woman of childbearing age, potent autocrine and paracrine peptide in obtain a negative pregnancy test before vascular smooth muscle and endothelium giving ambrisentan and then monthly of lung tissue. ET-1 levels increase in pul- during therapy. A positive result requires monary arterial hypertension, and ET-1 immediately stopping drug because of the may affect its development and progression. risk of serious birth defects. Ambrisentan blocks an ET-1 receptor sub- • Obtain liver enzyme levels, as ordered, type, ETA, that causes vasoconstriction and before starting ambrisentan therapy and cell proliferation, decreasing pulmonary monthly during therapy because drug may artery pressure and cell proliferation and significantly increase liver aminotrans- possibly delaying disease progression. ferase (ALT and AST) levels. If liver Contraindications enzymes are more than three times the Hypersensitivity to ambrisentan or its com- upper limit of normal. expect to not start ponents, pregnancy, breast-feeding, moder- ambrisentan. If they’re somewhat elevated, ate to severe hepatic disease expect to monitor bilirubin before and monthly during therapy. If liver enzymes Interactions become elevated during therapy and evi- DRUGS dence of hepatic dysfunction (abdominal cyclosporine A: Possibly increased exposure pain, fever, jaundice, nausea, vomiting, to ambrisentan unusual lethargy or fatigue) develops or strong CYP3A inhibitors (such as ketocona- patient’s bilirubin level exceeds twice the zole) and CYP2C19 inhibitors (such as upper limit of normal, notify prescriber omeprazole): Possibly increased plasma and expect to stop ambrisentan therapy. ambrisentan level and increased risk of tox- • Monitor patient’s hemoglobin level before icity starting ambrisentan, again after 1 month FOODS of therapy, and periodically thereafter. If grapefruit juice: Possibly increased blood level declines significantly, notify pre- ambrisentan level scriber and expect to discontinue drug.
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 60 60 amikacin sulfate • Assess patient closely for peripheral tions when penicillin is contraindicated edema, especially if elderly. If edema I.V. INFUSION, I.M. INJECTION becomes pronounced, notify prescriber. Adults and children. 15 mg/kg daily in Further evaluation will reveal whether it equal doses at equally spaced intervals (7.5 results from ambrisentan or another con- mg/kg every 12 hr or 5 mg/kg every 8 hr) dition, such as heart failure. for 7 to 10 days. Maximum: 1,500 mg daily. • If patient takes ambrisentan for longer DOSAGE ADJUSTMENT For patients with than 12 months, watch for hepatic cirrho- impaired renal function, loading dose of sis (abdominal pain, fever, jaundice, nau- 7.5 mg/kg daily; then maintenance dosage sea, vomiting, or unusual lethargy or based on creatinine clearance and serum fatigue). A similar drug, bosentan, rarely creatinine level and given every 12 hr. For has caused unexplained hepatic cirrhosis morbidly obese patients, dosage not to after being taken longer than 12 months. exceed 1.5 g daily. PATIENT TEACHING Neonates. Loading dose: 10 mg/kg. • Caution patient not to split, crush, or Maintenance: 7.5 mg/kg every 12 hr for 7 to chew ambrisentan tablets. 10 days. • Instruct female patient of childbearing age  To treat uncomplicated UTI to use two reliable forms of birth control I.V. INFUSION, I.M. INJECTION during therapy unless she has had a tubal Adults. 250 mg b.i.d. for 7 to 10 days. ligation or a Copper T 380A or LNg 20 intrauterine device inserted. Explain that Route Onset Peak Duration she’ll need monthly pregnancy test. I.V. Immediate Unknown Unknown • Inform male patient that sperm counts I.M. Rapid Unknown Unknown have declined in some men taking drugs similar to ambrisentan, affecting their Mechanism of Action ability to father children. If this concerns Binds to negatively charged sites on bacte- him, suggest that he consult prescriber. ria’s outer cell membrane, disrupting cell • Stress the need for follow-up visits and integrity. Also binds to bacterial ribosomal tests, such as hemoglobin checks. subunits and inhibits protein synthesis. • Advise patient to promptly report any Both actions lead to cell death. signs of liver dysfunction to the prescriber. • Instruct patient to notify prescriber about Incompatibilties fluid retention. Don’t mix or infuse amikacin with other drugs. Contraindications amikacin sulfate Hypersensitivity to amikacin or other Amikin aminoglycosides Interactions Class and Category DRUGS Chemical class: Aminoglycoside cephalosporins, enflurane, methoxyflurane, Therapeutic class: Antibiotic vancomycin: Increased nephrotoxic effects Pregnancy category: D general anesthetics: Increased risk of neuro- muscular blockade Indications and Dosages  To treat serious gram-negative bacterial loop diuretics: Increased risk of ototoxicity neuromuscular blockers: Possibly increased infections (including septicemia; neona- neuromuscular blockade and prolonged tal sepsis; respiratory tract, bone, joint, respiratory depression CNS, skin, soft-tissue, intra-abdominal, penicillins: Possibly inactivation of or syner- burn, and postoperative infections; and gistic effects with amikacin serious, complicated, and recurrent UTI) caused by Acinetobacter, Entero- Adverse Reactions bacter, Escherichia coli, Klebsiella, CNS: Drowsiness, headache, loss of balance, Proteus, Providencia, Pseudomonas, neuromuscular blockade, tremor, vertigo and Serratia; and staphylococcal infec- EENT: Hearing loss, ototoxicity, tinnitus
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 61 amiloride hydrochloride 61 GI: Nausea, vomiting patient with heart failure or hyperten- GU: Azotemia, dysuria, nephrotoxicity, oli- sion to correct diuretic-induced hypo- guria or polyuria, proteinuria A kalemia or to prevent diuretic-induced MS: Acute muscle paralysis; arthralgia; hypokalemia that increases the risk of muscle fatigue, spasms, and weakness arrhythmias or other complications RESP: Apnea TABLETS Other: Hyperkalemia Adults. 5 to 10 mg daily as single dose; if hypokalemia persists, increased to 15 mg Nursing Considerations daily and then 20 mg daily. • Expect to obtain results of culture and sensitivity testing before therapy begins. • Prepare amikacin I.V. solution by adding Route Onset Peak Duration contents of 500-mg vial to 100 to 200 ml P.O. 2 hr 6–10 hr 24 hr of sterile diluent. Then infuse drug over 30 to 60 minutes. Mechanism of Action • Give I.M. injection in large muscle mass. Inhibits sodium reabsorption in distal con- • Watch for signs of ototoxicity, such as tin- voluted tubules and cortical collecting nitus and vertigo, especially during high- ducts, causing sodium and water loss and dosage or prolonged amikacin therapy. enhancing potassium retention. WARNING Because amikacin may produce Contraindications nephrotoxic effects, assess renal function Hypersensitivity to amiloride; impaired before and daily during therapy, as renal function; serum potassium level above ordered. To minimize renal tubule irrita- 5.5 mEq/L; therapy with another potassium- tion, maintain hydration during therapy. sparing diuretic, such as spironolactone or • Be aware that amikacin may exacerbate triamterene, or a potassium supplement muscle weakness in such conditions as myasthenia gravis and Parkinson’s disease. Interactions • Measure serum amikacin concentrations DRUGS as ordered, usually 30 to 90 minutes after angiotensin II receptor antagonists, captopril, injection (for peak concentration) and just enalapril, lisinopril, potassium products, before administering next dose (for trough spironolactone: Increased risk of hyper- concentration). kalemia PATIENT TEACHING digoxin: Decreased effectiveness of digoxin • Tell patient that daily laboratory tests are lithium: Reduced renal clearance of lithium necessary during treatment. and increased risk of lithium toxicity • Instruct patient to report ringing in ears, NSAIDs: Reduced diuretic effect of hearing changes, headache, nausea, vomit- amiloride ing, and changes in urination. sympathomimetics: Possibly reduced antihy- pertensive effects of amiloride FOODS high-potassium food: Increased risk of amiloride hyperkalemia hydrochloride Adverse Reactions Midamor CNS: Confusion, depression, dizziness, drowsiness, encephalopathy, fatigue, headache, insomnia, nervousness, paresthe- Class and Category sia, somnolence, tremor, vertigo Chemical class: Pyrazine-carbonyl- CV: Angina, arrhythmias, orthostatic guanidine hypotension, palpitations Therapeutic class: Potassium-sparing diuret- EENT: Dry mouth, increased intraocular ic pressure, nasal congestion, tinnitus, vision Pregnancy category: B disturbances Indications and Dosages GI: Abdominal pain or fullness, anorexia,  As adjunct to thiazide or loop diuretic in appetite changes, constipation, diarrhea, GI
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 62 62 aminocaproic acid bleeding, heartburn, indigestion, nausea, I.V. INJECTION thirst, vomiting Adults. 4 to 5 g in 250 ml of diluent over GU: Bladder spasms, dysuria, impotence, 1 hr followed by continuous infusion of loss of libido, polyuria 1 g/hr in 50 ml of diluent. Continue for HEME: Aplastic anemia, neutropenia 8 hr or until bleeding stops. MS: Arthralgia, muscle spasms or weakness RESP: Cough, dyspnea Route Onset Peak Duration SKIN: Alopecia, jaundice, pruritus, rash P.O. Rapid Unknown Unknown Other: Dehydration, hyperchloremia, I.V. Immediate Unknown Under 3 hr hyperkalemia, hypernatremia, metabolic acidosis Mechanism of Action Nursing Considerations Inhibits breakdown of blood clots by inter- • Administer amiloride with food to reduce fering with plasminogen activator sub- GI upset and early in the day to minimize stances and producing antiplasmin activity. sleep interference from polyuria. Contraindications • Monitor renal function test results, fluid Hypersensitivity to aminocaproic acid; intake and output, and weight. Also moni- signs of active intravascular clotting, as in tor serum potassium level to detect hyper- disseminated intravascular coagulation; kalemia. upper urinary tract bleeding WARNING Don’t administer amiloride with other potassium-sparing diuretics. Interactions PATIENT TEACHING DRUGS • Warn patient to avoid high-potassium activated prothrombin, prothrombin complex food and salt substitutes that contain concentrates: Increased risk of thrombosis potassium. estrogens, oral contraceptives: Increased risk • Advise patient to consult prescriber before of hypercoagulation taking other drugs, including OTC reme- Adverse Reactions dies, especially sympathomimetics. CNS: Delirium, dizziness, hallucinations, • Tell patient to report dizziness, trembling, headache, malaise, stroke, weakness numbness, and muscle weakness or CV: Bradycardia, cardiomyopathy, elevated spasms. serum CK level, hypotension, ischemia, • Advise patient to increase fluid and fiber thrombophlebitis intake to prevent constipation. EENT: Nasal congestion, tinnitus • Warn patient to expect reversible hair loss GI: Abdominal cramps and pain, diarrhea, and impotence. elevated AST level, nausea, vomiting GU: Elevated BUN level, intrarenal obstruc- tion, renal failure aminocaproic acid HEME: Agranulocytosis, leukopenia, Amicar thrombocytopenia MS: Myopathy RESP: Dyspnea, pulmonary embolism Class and Category SKIN: Pruritus, rash Chemical class: Aminohexanoic acid Other: Elevated serum aldolase and potassi- Therapeutic class: Antifibrinolytic, anti- um levels hemorrhagic Pregnancy category: C Nursing Considerations • Be aware that patients on oral therapy may Indications and Dosages need up to 10 tablets during the first hour  To treat excessive bleeding caused by of treatment and tablets around the clock fibrinolysis during continued treatment. SYRUP, TABLETS • Mix aminocaproic acid solution with ster- Adults. Initial: 5 g in first hour, followed by ile water for injection, normal saline solu- 1 to 1.25 g/hr to sustain drug plasma level tion, D5W, or Ringer’s solution. of 0.13 mg/ml. Maximum: 30 g daily. WARNING Avoid rapid I.V. delivery because
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 63 aminoglutethimide; aminophylline 63 it increases risk of hypotension and brady- Adverse Reactions cardia. CNS: Dizziness, drowsiness, fever, headache • Monitor neurologic status for drug- CV: Hypotension, orthostatic hypotension, A induced changes. Note that increased clot- tachycardia ting may lead to stroke. ENDO: Adrenal insufficiency, hypothyroid- PATIENT TEACHING ism, masculinization • Tell patient that he’ll be closely monitored GI: Anorexia, nausea during I.V. therapy and will have blood SKIN: Hair growth, morbiliform rash, pru- drawn for laboratory tests before, during, ritus, urticaria and after treatment. Nursing Considerations • Advise patient who takes aminocaproic • Expect to reduce aminoglutethimide acid at home to report adverse reactions, dosage or discontinue treatment if take drug exactly as prescribed, and keep extreme drowsiness, severe rash, or exces- follow-up appointments with prescriber. sively low cortisol level occurs. WARNING Monitor for signs of hypothy- roidism, including lethargy, dry skin, and aminoglutethimide slow pulse. If prescribed, administer thy- Cytadren roid hormone supplement. • Monitor blood pressure for orthostatic or persistent hypotension. Class and Category PATIENT TEACHING Chemical class: Hormone • Teach patient to recognize orthostatic Therapeutic class: Adrenal steroid inhibitor hypotension (dizziness, weakness when Pregnancy category: D moving from sitting to standing position) Indications and Dosages and to minimize it (as by rising slowly  To suppress adrenal function in patients from a supine to an upright position). with Cushing’s syndrome who are wait- • Tell patient to report dizziness, appetite ing for surgery or for whom other treat- loss, nausea, headache, or severe drowsi- ment can’t be used ness. Warn him to avoid driving if drowsy. TABLETS • Instruct patient to take a missed dose as Adults. Initial: 250 mg every 6 hr. Increased soon as remembered and to evenly space as needed by 250 mg daily every 1 to 2 wk. out the day’s remaining doses. Maximum: 2,000 mg daily. • Advise patient that rash, sometimes accompanied by fever, may appear on day Route Onset Peak Duration 10 of treatment and should subside by day 15 or 16. Tell him to report severe rash or P.O. 3–5 days Unknown 72 hr one that doesn’t disappear. Mechanism of Action Inhibits the conversion of cholesterol to delta-5-pregnenolone, which is needed to aminophylline produce certain hormones, including ad- (theophylline renal glucocorticoids, mineralocorticoids, ethylenediamine) estrogens, and androgens. Phyllocontin, Truphylline Contraindications Hypersensitivity to aminoglutethimide or Class and Category glutethimide Chemical class: Xanthine Therapeutic class: Bronchodilator Interactions Pregnancy category: C DRUGS antidiabetics, dexamethasone, digoxin, med- Indications and Dosages roxyprogesterone, synthetic glucocorticoids,  To relieve acute bronchospasm theophylline, warfarin and other oral antico- I.V. INFUSION agulants: Decreased effects of these drugs Adults and children not currently receiv-
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 64 64 aminophylline ing theophylline products. Initial: 6 mg/kg dosage increased in increments of 2 to (equal to 4.7 mg/kg anhydrous theo- 3 mg/kg every 3 days. When maximum phylline), not to exceed 25 mg/min. dose is reached, dosage adjusted according Maintenance: For adults (nonsmokers), to peak serum theophylline level. 0.7 mg/kg/hr for first 12 hr, then 0.5 mg/kg/ hr. For children ages 9 to 16, 1 mg/kg/hr for Route Onset Peak Duration first 12 hr, then 0.8 mg/kg/hr. For children P.O. (E.R.) Unknown Unknown 8–12 hr ages 6 months to 9 years and young adult P.O. (tab) Unknown Unknown 6–8 hr smokers, 1.2 mg/kg/hr for first 12 hr, then I.V. Immediate Unknown 4–8 hr 1 mg/kg/hr. Adults and children currently receiving Mechanism of Action theophylline products. Initial: If possible, Inhibits phosphodiesterase enzymes, caus- determine the time, amount, administra- ing bronchodilation. Normally, these tion route, and form of last dose. Loading enzymes inactivate cyclic adenosine dose is based on the principle that each monophosphate (cAMP) and cyclic guano- 0.63 mg/kg (0.5 mg/kg anhydrous theo- sine monophosphate (cGMP), which are phylline) given raises serum theophylline responsible for bronchial smooth-muscle level by 1 mcg/ml. Defer loading dose if relaxation. Other mechanisms of action serum theophylline level can be readily may include translocation of calcium, obtained. If this isn’t possible and patient prostaglandin antagonism, stimulation of has no obvious signs of theophylline toxici- catecholamines, inhibition of cGMP metab- ty, prescriber may order 3.1 mg/kg (2.5 mg/ olism, and adenosine receptor antagonism. kg anhydrous theophylline), which may increase serum theophylline level by about Incompatibilities 5 mcg/ml. Maintenance: For adults (non- Don’t add other drugs to prepared bag or smokers), 0.7 mg/kg/hr for first 12 hr, then bottle of aminophylline. Don’t mix amino- 0.5 mg/kg/hr. For children ages 9 to 16, 1 phylline in same syringe with doxapram. mg/kg/hr for first 12 hr, then 0.8 mg/kg/hr. Also avoid administering amiodarone, For children ages 6 months to 9 years and ciprofloxacin, diltiazem, dobutamine, young adult smokers, 1.2 mg/kg/hr for first hydralazine, or ondansetron into the Y-port 12 hr, then 1 mg/kg/hr. of a continuous infusion of aminophylline. DOSAGE ADJUSTMENT For elderly patients Contraindications and those with cor pulmonale, dosage Active peptic ulcer disease, hypersensitivity reduced to 0.6 mg/kg for 12 hr, then to aminophylline, rectal or lower intestine 0.3 mg/kg. For patients with heart failure irritation or infection (suppository form), and hepatic disease, dosage reduced to underlying seizure disorder 0.5 mg/kg for 12 hr, then 0.1 to 0.2 mg/kg.  To prevent or treat reversible bron- Interactions chospasm from asthma, chronic bronchi- DRUGS tis, and emphysema and to maintain activated charcoal, aminoglutethimide, bar- patent airways biturates, ketoconazole, rifampin, sulfinpyra- E.R. TABLETS, ORAL LIQUID, TABLETS, SUPPOSITORIES zone, sympathomimetics: Decreased serum Adults and children. Initial (rapidly theophylline level absorbed forms): 16 mg/kg daily or 400 mg allopurinol, calcium channel blockers, cimeti- daily (whichever is less) in divided doses dine, corticosteroids, disulfiram, ephedrine, every 6 to 8 hr. Maintenance: Daily dosage influenza virus vaccine, interferon, macro- increased in increments of 25% every lides, mexiletine, nonselective beta blockers, 3 days, as tolerated, until response achieved oral contraceptives, quinolones, thiabenda- or maximum dose reached. When maxi- zole: Increased serum theophylline level mum dose is reached, dosage adjusted benzodiazepines: Antagonized sedative according to peak serum theophylline level. effects of benzodiazepines Initial (E.R. forms): 12 mg/kg daily or beta agonists: Increased effects of amino- 400 mg daily (whichever is less) in divided phylline and beta agonist doses every 8 to 12 hr. Maintenance: Daily carbamazepine, isoniazid, loop diuretics:
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 65 aminosalicylate sodium 65 Altered serum theophylline level theophylline result. halothane: Increased risk of cardiotoxicity • To determine peak serum theophylline hydantoins: Decreased hydantoin level level, draw blood sample 15 to 30 minutes A ketamine: Increased risk of seizures after administering I.V. loading dose. lithium: Decreased serum lithium level • Give immediate-release and liquid forms nondepolarizing muscle relaxants: Reversed with food to reduce GI upset. Give E.R. neuromuscular blockade form 1 hour before or 2 hours after meals propofol: Antagonized sedative effects of because food can alter drug absorption. propofol PATIENT TEACHING tetracyclines: Enhanced adverse effects of • Advise patient to avoid excessive caffeine theophylline (in coffee, tea, soft drinks, and chocolate); FOODS it can falsely elevate theophylline level. all foods: Altered bioavailability and absorp- • Explain that blood tests may be needed to tion of E.R. form, leading to toxicity monitor drug’s therapeutic effect. high-carbohydrate, low-protein diet: Decreased theophylline elimination and prolonged aminophylline half-life aminosalicylate low-carbohydrate, high-protein diet; char- broiled beef: Increased theophylline elimina- sodium tion and shortened aminophylline half-life (para-aminosalicylate, ACTIVITIES alcohol abuse: Increased aminophylline effects PAS) smoking (1 or more packs daily): Decreased Nemasol Sodium (CAN), PAS effects of aminophylline Adverse Reactions Class and Category CNS: Dizziness, fever, headache, insomnia, Chemical class: Para-aminobenzoic acid irritability, restlessness, seizures analogue CV: Arrhythmias (including sinus tachycar- Therapeutic class: Antitubercular dia and life-threatening ventricular arrhyth- Pregnancy category: C mias), hypotension, palpitations Indications and Dosages EENT: Bitter aftertaste  To treat tuberculosis as adjunct to isoni- ENDO: Hyperglycemia, syndrome of inap- azid, streptomycin, or both and in propriate ADH secretion patients with multidrug-resistant tuber- GI: Anorexia, diarrhea, epigastric pain, culosis or when therapy with rifampin heavy feeling in stomach, hematemesis, and isoniazid isn’t possible because of indigestion, nausea, rectal bleeding or irri- resistance or intolerance tation (suppositories), vomiting TABLETS GU: Diuresis, proteinuria, urine retention Adults. 14 to 16 g daily in 2 or 3 divided in men with prostate enlargement doses. MS: Muscle twitching Children. 275 to 420 mg/kg daily in 3 or RESP: Respiratory arrest, tachypnea 4 divided doses. SKIN: Alopecia, exfoliative dermatitis, flushing, rash, urticaria Mechanism of Action Inhibits incorporation of para-aminoben- Nursing Considerations zoic acid into folic acid and prevents syn- WARNING Because aminophylline has a nar- thesis of folic acid, a compound needed for row therapeutic window (10 to 20 mcg/ bacterial growth. Aminosalicylate sodium is ml), closely monitor serum theophylline bacteriostatic against Mycobacterium tuber- level and watch for evidence of toxicity culosis, and it delays bacterial resistance to (tachycardia, tachypnea, nausea, vomiting, streptomycin and isoniazid. restlessness, seizures). Keep in mind that acetaminophen, furosemide, phenylbuta- Contraindications zone, probenecid, theobromine, coffee, tea, Hypersensitivity to aminosalicylate sodium, soft drinks, and chocolate can alter serum severe renal disease
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 66 66 amiodarone hydrochloride Interactions 1 mo; then if cardiac rhythm is stable, DRUGS 400 mg daily in 1 or 2 doses. Use lowest digoxin: Decreased serum digoxin level possible dose. probenecid: Increased serum aminosalicylate I.V. INFUSION level Adults. Loading: 150 mg over 10 min (15 mg/ rifampin: Decreased serum rifampin level min) followed by 360 mg infused over 6 hr (1 mg/min). Maintenance: 540 mg infused Adverse Reactions over 18 hr (0.5 mg/min); then after the first CNS: Encephalopathy, fever 24 hr, 720 mg infused over 24 hr (0.5 mg/ CV: Vasculitis min), continued up to 2 to 3 wk, as needed. ENDO: Goiter with or without myxedema Rate may be increased in first 24 hr, if GI: Abdominal pain, diarrhea, hepatitis, needed, but initial infusion rate shouldn’t nausea, vomiting exceed 30 mg/min. Change to oral form as HEME: Agranulocytosis, hemolytic anemia, soon as possible. leukopenia, thrombocytopenia  To treat breakthrough episodes of ven- SKIN: Jaundice, various types of eruptions tricular fibrillation or hemodynamically Other: Infectious mononucleosis-like syn- unstable ventricular tachycardia drome, Loeffler’s syndrome (anorexia, I.V. INFUSION (NEXTERONE) breathlessness, fever, and weight loss) Adults. 150 mg mixed in 100 ml D5W and Nursing Considerations infused over 10 min (15 mg/min). • Administer aminosalicylate with food to reduce GI upset. Route Onset Peak Duration WARNING Protect drug from water, heat, P.O. 2 days– 1–5 mo Weeks– and sunlight to prevent rapid deteriora- 3 wk months tion. Don’t give tablets with brown or pur- I.V. Hours– 1–3 wk Weeks– ple discoloration—a sign of deterioration. 3 days months PATIENT TEACHING • Teach patient to discard aminosalicylate that appears brown or purple. Mechanism of Action • Instruct patient to take drug with food. Acts on cardiac cell membranes, prolonging repolarization and the refractory period and raising ventricular fibrillation thresh- old. Drug relaxes vascular smooth muscles, amiodarone mainly in coronary circulation, and hydrochloride improves myocardial blood flow. It relaxes peripheral vascular smooth muscles, Cordarone, Nexterone, Pacerone decreasing peripheral vascular resistance and myocardial oxygen consumption. Class and Category Chemical class: Iodinated benzofuran Incompatibilities derivative Amiodarone is incompatible with heparin. Therapeutic class: Class III antiarrhythmic To prevent precipitation, don’t add amio- Pregnancy category: D darone admixed with D5W to amino- phylline 4 mg/ml, cefamandole nafate, cefa- Indications and Dosages zolin sodium, or mezlocillin sodium, and  To treat life-threatening, recurrent ven- don’t mix amiodarone 3 mg/ml with sodi- tricular fibrillation and hemodynami- um bicarbonate. Also, don’t use evacuated cally unstable ventricular tachycardia glass containers for admixing because pre- when these arrhythmias don’t respond to cipitation may occur. other drugs or when patient can’t toler- ate other drugs Contraindications TABLETS Bradycardia that causes syncope (unless Adults. Loading: 800 to 1,600 mg daily in pacemaker present), cardiogenic shock, divided doses for 1 to 3 wk. Maintenance: hypersensitivity to amiodarone or its com- 600 to 800 mg daily in divided doses for ponents, hypokalemia, hypomagnesemia,
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 67 amiodarone hydrochloride 67 SA node dysfunction, second- and third- quinidine: Increased serum quinidine level degree AV block (unless pacemaker present) with risk of life-threatening arrhythmias ritonavir: Increased serum amiodarone level A Interactions with increased risk of cardiotoxicity DRUGS theophylline: Increased serum theophylline anticoagulants: Increased anticoagulant level; increased risk of theophylline toxicity response and possibly serious bleeding warfarin: Increased PT and risk of bleeding azole antifungals, fluoroquinolones, macro- FOODS lide antibiotics: Increased risk of prolonged grapefruit juice: Increased amiodarone level QT interval and life-threatening arrhyth- mias Adverse Reactions beta blockers: Increased serum levels of beta CNS: Abnormal gait, ataxia, confusion, blockers with increased risk of AV block, delirium, demyelinating polyneuropathy, hypotension, and bradycardia disorientation, dizziness, fatigue, fever, hal- calcium channel blockers: Increased serum lucinations, headache, insomnia, involun- levels of these drugs and increased risk of tary motor activity, lack of coordination, AV block, bradycardia, and hypotension malaise, paresthesia, parkinsonian symp- cholestyramine, phenytoin, rifampin, St. toms, peripheral neuropathy, pseudotumor John’s wort: Decreased amiodarone level cerebri, sleep disturbances, tremor cimetidine: Increased amiodarone level CV: Arrhythmias (including bradycardia, clopidogrel: Increased risk of ineffective electromechanical dissociation, torsades de inhibition of platelet aggregation pointes, and ventricular tachycardia or fib- cyclosporine: Increased cyclosporine level rillation), cardiac arrest, cardiogenic shock, dextromethorphan, methotrexate, phenytoin: edema, heart failure, hypotension, vasculitis Increased serum levels of these drugs and EENT: Abnormal salivation, abnormal taste increased risk of toxicity if amiodarone is and smell, blurred vision, corneal microde- taken orally for more than 2 weeks posits, dry eyes, halo vision, lens opacities, digoxin: Increased serum digoxin level and macular degeneration, optic neuritis, optic risk of digitalis toxicity neuropathy, papilledema, permanent blind- diltiazem, propranolol, verapamil: Increased ness, photophobia, scotoma risk of hemodynamic and electrophysiolog- ENDO: Hyperthyroidism, hypothyroidism, ic abnormalities syndrome of inappropriate ADH secretion, disopyramide: Increased serum disopyra- thyroid cancer mide level with QT prolongation and GI: Abdominal pain, anorexia, cirrhosis, increased risk of arrhythmias constipation, diarrhea, elevated liver func- fentanyl: Increased serum fentanyl level tion test results, hepatitis, nausea, pancre- with increased risk of bradycardia, atitis, vomiting decreased cardiac output, and hypotension GU: Acute renal failure, decreased libido, flecainide: Increased serum flecainide level epididymitis, impotence HMG-CoA reductase inhibitors such as ator- HEME: Agranulocytosis, aplastic or vastatin and simvastatin: Increased risk of hemolytic anemia, coagulation abnormali- myopathy and rhabdomyolysis ties, neutropenia, pancytopenia, sponta- hydantoins: Increased serum hydantoin neous bruising, thrombocytopenia level with long-term use and reduced serum MS: Muscle weakness, myopathy, rhab- amiodarone level domyolysis lidocaine: Increased serum lidocaine level RESP: Acute respiratory distress syndrome; and risk of seizures and bradycardia bronchospasm; eosinophilic pneumonia; loratadine, trazodone: Increased risk of QT- infiltrates that lead to dyspnea, cough, interval prolongation and torsades de hemoptysis, hypoxia, pulmonary fibrosis, pointes pulmonary alveolar hemorrhage, pul- potassium- and magnesium-depleting drugs: monary interstitial pneumonitis, crackles, Increased risk of hypokalemia and hypo- and wheezing; pleural effusion; pleuritis; magnesemia pneumonia; respiratory arrest or failure procainamide: Increased serum pro- SKIN: Alopecia, bluish gray pigmentation, cainamide or N-acetylprocainamide level eczema, erythema multiforme, exfoliative
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 68 68 amitriptyline hydrochloride dermatitis, flushing, photosensitivity, pruri- mia occur, notify prescriber at once. tus, rash, skin cancer, Stevens-Johnson syn- PATIENT TEACHING drome, toxic epidermal necrolysis, urticaria • Explain that patient will need frequent Other: Anaphylactic shock, angioedema monitoring and laboratory tests during treatment. Nursing Considerations • Advise patient to report swollen hands • If patient has an implantable cardiac and feet, wheezing, dyspnea, cough, nau- device, have it checked, as ordered, at the sea, vomiting, dark urine, fatigue, yellow start of and during amiodarone therapy skin or sclerae, stomach pain, light-head- because drug may affect pacing or defibril- edness, fainting, or a rapid, slow, pound- lating thresholds. ing, or irregular heartbeat. • Parenteral amiodarone may be diluted in • Instruct patient to report abnormal bleed- D5W or normal saline solution and given ing or bruising. in polyvinvyl chloride (PVC), polyolefin, • Advise patient to avoid corneal refractive or glass containers. laser surgery while taking drug. • Use an in-line filter during I.V. adminis- tration of amiodarone. Also use a central venous catheter whenever possible. A cen- tral venous catheter is required when infu- amitriptyline sion rate exceeds 2 mg/ml because drug may cause peripheral vein phlebitis at hydrochloride higher rates. Cordarone I.V. must be given Apo-amitriptyline (CAN), Endep, Levate by volumetric infusion pump. (CAN), Novotriptyn (CAN) • Monitor amiodarone I.V. infusion closely because loading doses at higher concentra- Class and Category tions and rates may cause hepatocellular Chemical class: Tertiary amine necrosis, acute renal failure, and death. Therapeutic class: Tricyclic antidepressant • Although maintenance therapy usually is Pregnancy category: D needed for only up to 96 hours, infusion of up to 0.5 mg/minute may be continued Indications and Dosages for 2 to 3 weeks regardless of patient’s age,  To relieve depression, especially when renal function, or left ventricular function. accompanied by anxiety and insomnia WARNING Amiodarone may cause or wors- TABLETS en pulmonary disorders that may develop Adults and children over age 12. Out- days to weeks after therapy and progress to patient: 75 mg daily in divided doses, respiratory failure or even death. Expect to increased to 150 mg daily, if needed. In- obtain chext x-ray and pulmonary func- patient: 100 mg daily, gradually increased to tion tests before therapy starts and then 300 mg daily, if needed. Maintenance: 40 to chest x-ray and follow-up exams every 100 mg daily at bedtime. 3 to 6 months during therapy. DOSAGE ADJUSTMENT Maintenance dosage • Monitor vital signs and oxygen level often reduced to 10 mg t.i.d. plus 20 mg at bed- during and after giving amiodarone. Keep time for adolescent and elderly patients. emergency equipment and drugs nearby. WARNING Monitor continuous ECG; check Route Onset Peak Duration for increased PR and QRS intervals, P.O. 14–21 Unknown Unknown arrhythmias, and heart rate below days 60 beats/min because amiodarone toxicity may cause or worsen arrhythmias. Contraindications • Monitor serum amiodarone level, which Acute recovery phase after MI, hypersensi- normally ranges from 1.0 to 2.5 mcg/ml. tivity to amitriptyline, MAO inhibitor ther- • Assess liver enzyme and thyroid hormone apy within 14 days levels; drug inhibits conversion of T4 to T3 and may cause drug-induced hyperthy- Interactions roidism, thyrotoxicosis, and new or wors- DRUGS ened arrhythmias. If new signs of arrhyth- anticholinergics, epinephrine, norepineph-
  • 92381_Axxx_p0017-0122 6/1/10 10:05 PM Page 69 amitriptyline hydrochloride 69 Mechanism of Action Normally, when an impulse reaches shown below on the left. A adrenergic nerves, the nerves release sero- Amitriptyline blocks serotonin and tonin and norepinephrine from their norepinephrine reuptake by adrenergic storage sites. Some serotonin and norepi- nerves. By doing so, it raises serotonin nephrine reaches receptor sites on target and norepinephrine levels at nerve tissues. Most is taken back into the nerves synapses. This action may elevate mood and stored by the reuptake mechanism, as and reduce depression. Nerve impulse Adrenergic nerve Norepinephrine Serotonin