100 NCLEX Drugs

clopidogrel

Plavix Class and Category Chemical class: Thienopyridine derivative Therapeutic class: Platelet aggregation inhibitor Pregnancy category: B Indications and Dosages To reduce atherosclerotic events, such as stroke and MI, in patients with atherosclerosis documented by recent stroke, MI, or peripheral artery disease Tablets Adults. 75 mg daily. To reduce atherosclerotic events, such as stroke and MI, in patients with acute coronary syndrome (unstable angina or non-Q-wave MI) Tablets Adults. Loading dose: 300 mg. Maintenance: 75 mg daily To reduce rate of death, reinfarction, or stroke in patients with ST-segment elevation acute MI Tablets Adults. 75 mg once daily. Or, loading dose of 300 mg followed by 75 mg once daily. Route Onset Peak Duration P.O. 2 hr 3 to 7 days* 5 days Mechanism of Action Binds to adenosine diphosphate (ADP) receptors on the surface of activated platelets. This action blocks ADP, which deactivates nearby glycoprotein IIb/IIIa receptors and prevents fibrinogen from attaching to receptors. Without fibrinogen, platelets can't aggregate and form thrombi. Contraindications Active pathological bleeding, including peptic ulcer and intracranial hemorrhage; hypersensitivity to clopidogrel or its components Interactions Drugs aspirin: Increased risk of bleeding fluvastatin, phenytoin, tamoxifen, tolbutamide, torsemide: Interference with metabolism of these drugs NSAIDs: Increased risk of GI bleeding, interference with NSAID metabolism warfarin: Prolonged bleeding time, interference with warfarin metabolism Adverse Reactions CNS: Confusion, depression, dizziness, fatigue, hallucinations, headache CV: Chest pain, edema, hypercholesterolemia, hypertension, hypotension, vasculitis EENT: Altered taste; conjunctival, ocular, or retinal bleeding; epistaxis; rhinitis; taste disorders GI: Abdominal pain; acute liver failure; colitis; diarrhea; duodenal, gastric, or peptic ulcer; elevated liver function test results; gastritis; indigestion; nausea; noninfectious hepatitis; pancreatitis GU: Elevated serum creatinine level, glomerulopathy, UTI HEME:, Agranulocytosis, aplastic anemia, neutropenia, pancytopenia, prolonged bleeding time thrombocytopenic purpura, thrombotic thrombocytopenic purpura, unusual bleeding or bruising MS: Arthralgia, back pain, myalgia RESP: Bronchitis, bronchospasm, cough, dyspnea, interstitial pneumonitis, upper respiratory tract infection SKIN: Erythema multiforme, lichen planus, pruritus, purpura, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis Other: Anaphylaxis, angioedema, flulike symptoms, serum sickness Nursing Considerations Use clopidogrel cautiously in patients with severe hepatic or renal disease, risk of bleeding from trauma or surgery, or conditions that predispose to bleeding (such as peptic ulcer disease or thrombotic thrombocytopenic purpura). In patient with acute coronary syndrome, expect to give aspirin with clopidogrel. WARNING Clopidogrel prolongs bleeding time; expect to stop it 5 days before elective surgery. Obtain blood cell count, as ordered, whenever signs and symptoms suggest a hematologic problem. Monitor patient who takes aspirin closely because risk of bleeding is increased. Patient Teaching Discourage the use of NSAIDs, including OTC preparations, during clopidogrel therapy because of potential for bleeding. Caution patient that bleeding may continue for longer than usual. Instruct him to notify prescriber about unusual bleeding or bruising. Because he has an increased risk of bleeding, urge patient to inform all other health care providers, including dentists, that he takes clopidogrel before having surgery or other procedures or taking a new drug. Instruct patient to inform his health care providers about his clopidogrel therapy.

Fentanyl

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atenolol

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Acetaminophen

Abenol (CAN), Acephen, Aceta Elixir, Acetaminophen Uniserts, Aceta Tablets, Apacet Capsules, Apacet Elixir, Apacet Extra Strength Tablets, Apacet Regular Strength Tablets, Aspirin-Free Pain Relief, Exdol (CAN), Feverall, Feverall Sprinkle Caps, Genapap Infants' Drops, Genebs Extra Strength, Halenol Children's Junior Strength, Liquiprin Elixir, Liquiprin Infants' Drops, Meda Cap, Neopap, Oraphen-PD, Panadol, Panadol Infants' Drops, Pediaphen, Redutemp, Robigesic (CAN), St. Joseph Aspirin-Free Infant Drops, Tapanol Extra Strength, Tempra, Tempra Drops, Tylenol, Tylenol Caplets, Tylenol Children's Chewable Tablets, Tylenol Extra Strength, Tylenol Gelcaps, Tylenol Infants' Drops, Parenteral: Ofirmev. Class and Category Chemical class: Nonsalicylate, para-aminophenol derivative Therapeutic class: Antipyretic, nonopioid analgesic Pregnancy category: B Indications and Dosages To relieve mild to moderate pain from headache, muscle ache, backache, minor arthritis, common cold, toothache, or menstrual cramps; to reduce fever REGULAR STRENGTH (325 MG): CAPLETS, CAPSULES, CHEWABLE TABLETS, ELIXIR, GELCAPS, LIQUID SOLUTION, SPRINKLES, SUSPENSION, TABLETS Adults and children 12 yrs and over. 650 mg (2 tablets) every 4 to 6 hr, as needed. Maximum: 3,250 mg (5 doses) in 24 hr. Children ages 6 to 11 yr. 325 mg (1 tablet) every 4 to 6 hr, as needed. Maximum: 1,625 mg (5 doses) in 24 hr. JUNIOR CHEWABLE TABLETS (160 MG/TABLET), JUNIOR MELTAWAYS (160 MG/TABLET) Children age 11 . 480 mg (3 tablets) every 4 hr, as needed. Maximum: 2,400 mg (5 doses) in 24 hr. Children ages 9 and 10. 400 mg (2.5 tablets) every 4 hr, as needed. Maximum: 2,000 mg (5 doses) in 24 hr. Children ages 6 to 8 . 320 mg (2 tablets) every 4 hr, as needed. Maximum: 1,600 mg (5 doses) in 24 hr. CHILDREN'S SUSPENSION (160 MG/5 ML), CHILDREN'S CHEWABLE TABLETS (80 MG/TABLET), CHILDREN'S MELTAWAYS (80 MG/TABLET) Children age 11 . 480 mg (15 ml or 6 tablets) every 4 hr, as needed. Maximum: 2,400 mg (5 doses) in 24 hr. Children ages 9 and 10. 400 mg (12.5 ml or 5 tablets) every 4 hr, as needed. Maximum: 2,000 mg (5 doses) in 24 hr. Children ages 6 to 8. 320 mg (10 ml or 4 tablets) every 4 hr, as needed. Maximum: 1,600 mg (5 doses) in 24 hr. Children ages 4 and 5. 240 mg (7.5 mg or 3 tablets) every 4 hr, as needed. Maximum: 1,200 mg (5 doses) in 24 hr. Children ages 2 and 3 . 160 mg (5 ml or 2 tablets) every 4 hr, as needed. Maximum: 800 mg (5 doses) in 24 hr. Children under age 2 : Individualized. 8 HR E.R. CAPLETS (650 MG/CAPLET) Adults and children age 12 and over . 1,300 mg (2 caplets) q 8 hr, as needed. Maximum: 3,900 mg (3 doses) in 24 hr. EXTRA-STRENGTH (500 MG): CAPLETS, RAPID-RELEASE GELCAPS, EZ TABS Adults and children age 12 and over. 500 mg (2 caplets, gelcaps, tabs) q 6 hr, as needed. Maximum: 3,000 mg (3 doses) in 24 hr. EXTRA-STRENGTH RAPID-RELEASE LIQUID (1,000 MG PER 30 ML) Adults and children age 12 and over. 1,000 mg (30 ml) q 6 hr, as needed. Maximum: 3,000 mg (3 doses) in 24 hr. SUPPOSITORIES Adults and adolescents. 650 mg every 4 to 6 hr, as needed. Maximum: 3,000 mg in 24 hr. Children ages 6 to 12. 325 mg every 4 to 6 hr, as needed. Maximum: 1,950 mg in 24 hr. Children ages 3 to 6. 120 to 125 mg every 4 to 6 hr, as needed. Maximum: 750 mg in 24 hr. Children ages 1 to 3. 80 mg every 4 hr, as needed. Maximum: 480 mg in 24 hr. Children ages 3 months to 11 months. 80 mg every 6 hr, as needed. Maximum: 320 mg in 24 hr. To relieve mild to moderate pain; to manage moderate to severe pain with adjunctive opioid analgesics; to reduce fever I.V. INFUSION Adults and adolescents age 13 and over weighing 50 kg (110 lb) or more. 650 mg administered over 15 min every 4 hr, as needed, or 1,000 mg administered over 15 min every 6 hr, as needed. Maximum: 4,000 mg in 24 hr. Adults and adolescents age 13 and over, and children age 2 and over weighing less than 50 kg (110 lb). 12.5 mg/kg administered over 15 min every 4 hr, as needed, or 15 mg/kg (up to 750 mg) administered over 15 min every 6 hr, as needed. Maximum: 75 mg/kg in 24 hr. Mechanism of Action Inhibits the enzyme cyclooxygenase, blocking prostaglandin production and interfering with pain impulse generation in the peripheral nervous system. Acetaminophen also acts directly on temperature-regulating center in the hypothalamus by inhibiting synthesis of prostaglandin E2. Incompatibilities Don't mix parenteral acetaminophen with any other medication. Diazepam and chlorpromazine are physically incompatible with parenteral acetaminophen. Contraindications Hypersensitivity to acetaminophen or its components, severe hepatic impairment, severe active liver disease Interaction DRUGS anticholinergics: Decreased onset of acetaminophen action barbiturates, carbamazepine, hydantoins, isoniazid, rifampin, sulfinpyrazone: Decreased therapeutic effects and increased hepatotoxic effects of acetaminophen lamotrigine, loop diuretics: Possibly decreased therapeutic effects of these drugs oral contraceptives: Decreased effectiveness of acetaminophen probenecid: Possibly increased therapeutic effects of acetaminophen propranolol: Possibly increased action of acetaminophen warfarin: Possibly increased international normalized ratio zidovudine: Possibly decreased zidovudine effects alcohol use: Increased risk of hepatotoxicity Adverse Reactions GI: Abdominal pain, hepatotoxicity (possibly severe), nausea, vomiting HEME: Hemolytic anemia (with long-term use), leukopenia, neutropenia, pancytopenia, thrombocytopenia SKIN: Jaundice, pruritus, rash, urticaria Other: Anaphylaxis, angioedema, hypersensitivity reaction, hypoglycemic coma Nursing Considerations Use acetaminophen cautiously in patients with hepatic impairment or active hepatic disease, alcoholism, chronic malnutrition, severe hypovolemia, or severe renal impairment. Before and during long-term therapy, monitor liver function test results, including AST, ALT, bilirubin, and creatinine levels, as ordered. Monitor renal function in patient on long-term therapy. Keep in mind that blood or albumin in urine may indicate nephritis; decreased urine output may indicate renal failure; and dark brown urine may indicate presence of the metabolite phenacetin. Expect to reduce dosage for patients with renal dysfunction. Store suppositories under 80? F (26.6? C). Be aware that patients weighing 50 kg (110 lb) or more and requiring 1,000-mg doses of parenteral acetaminophen (Ofirmev) can have the dose administered by inserting a vented intravenous set through the septum of the 100-ml vial. Further dilution is not required. For doses less than 1,000 mg, the appropriate dose must be withdrawn from the vial and placed into a separate container prior to administration to prevent inadvertent overdose. Place small-volume pediatric doses up to 60 ml in a syringe and administer over 15 minutes using a syringe pump. Monitor the end of a parenteral infusion to prevent possibility of air embolism. Use parenteral drug within 6 hours once vacuum seal of glass vial has been penetrated or contents transferred to another container. PATIENT TEACHING Tell patient that tablets may be crushed or swallowed whole. Concentrated infant drops are being phased out and are no longer manufactured, but may still be available. Instruct patient to read manufacturer's label and follow dosage guidelines precisely. Explain that infants' and children's acetaminophen liquid aren't equal in drug concentration and aren't interchangeable. Until concentrated infant drops are completely phased out, parents should use extra caution to ensure the correct dose is given with strength being used. Tell them to use only the measuring device that comes with the bottle to help ensure accurate dosage. Caution patient not to exceed recommended dosage or take other drugs containing acetaminophen at the same time because of risk of liver damage. Advise him to contact prescriber before taking other prescription or OTC products because they may contain acetaminophen. Teach patient to recognize signs of hepatotoxicity, such as bleeding, easy bruising, and malaise, which commonly occurs with chronic overdose.

nifedipine

Adalat, Adalat CC, Adalat PA (CAN), Adalat XL (CAN), Apo-Nifed (CAN), Novo-Nifedin (CAN), Nu-Nifed (CAN), Procardia, Procardia XL Class and Category Chemical class: Dihydropyridine derivative Therapeutic class: Antianginal, antihypertensive Pregnancy category: C Indications and Dosages To manage angina Capsules (Adalat,Apo-Nifed, Novo-Nifedin, Nu-Nifed, Procardia) Adults. Initial: 10 mg t.i.d., increased over 1 to 2 wk as needed. Maintenance: 10 to 20 mg t.i.d. Maximum: 180 mg daily, 30 mg/ dose. E.R.tablets (Adalat XL, Procardia XL) Adults. Initial: 30 to 60 mg daily, increased or decreased over 7 to 14 days based on patient response. Maximum: 90 mg daily. To manage hypertension E.R.tablets (Adalat CC) Adults. Initial: 30 mg daily. Maintenance: 30 to 60 mg daily, increased or decreased over 7 to 14 days based on patient response. Maximum: 90 mg daily. E.R.tablets (Adalat PA) Adults. Initial: 10 to 20 mg b.i.d., increased every 3 wk based on patient response. Maintenance: 20 mg b.i.d. Maximum: 80 mg daily. E.R.tablets (Adalat XL) Adults. Initial: 30 to 60 mg daily, increased or decreased over 7 to 14 days based on patient response. Maintenance: 60 to 90 mg daily. Maximum: 120 mg daily. E.R.tablets (Procardia XL) Adults. 30 to 60 mg daily, increased or decreased over 7 to 14 days based on patient response. Maximum: 120 mg daily. Route Onset Peak Duration P.O. (cap) 20 min Unknown Unknown Mechanism of Action May slow movement of calcium into myocardial and vascular smooth-muscle cells by deforming calcium channels in cell membranes, inhibiting ion-controlled gating mechanisms, and disrupting calcium release from sarcoplasmic reticulum. Decreasing intracellular calcium level inhibits smooth-muscle cell contraction and dilates arteries, which decreases myocar-dial oxygen demand, peripheral resistance, blood pressure, and afterload. Contraindications Hypersensitivity to a calcium channel blocker, second- or third-degree AV block without artificial pacemaker, sick sinus syndrome Interactions Drugs anesthetics (hydrocarbon inhalation): Possibly hypotension antiviral drugs, cimetidine, dalfopristin, diltiazem, erythromycin, fluconazole, itraconazole, ketoconazole, nefazodone, other antihypertensives, prazocin, quinupristin, timolol, valproic acid, verapamil: Increased risk of hypotension benazepril: Possibly increased heart rate and hypotensive effect beta blockers: Increased risk of profound hypotension, heart failure, and worsening of angina calcium supplements: Possibly interference with action of nifedipine carbamazepine, NSAIDs, phenobarbitone, phenytoin, rifampin, rifapentine, St. John's wort, sympathomimetics: Possibly decreased therapeutic effects of nifedipine digoxin: Transiently increased blood digoxin level, increased risk of digitalis toxicity disopyramide, flecainide: Increased risk of bradycardia, conduction defects, and heart failure doxazocin: Decreased doxazocin effectiveness; increased nifedipine effectiveness estrogens: Possibly increased fluid retention and decreased therapeutic effects of nifedipine lithium: Increased risk of neurotoxicity metformin: Increased metformin absorption and plasma level tacrolimus: Decreased tacrolimus metabolism Foods grapefruit, grapefruit juice: Possibly increased bioavailability of nifedipine high-fat meals: Possibly delayed nifedipine absorption Activities alcohol use: Additive hypotensive effect Adverse Reactions CNS: Anxiety, ataxia, confusion, dizziness, drowsiness, headache, nervousness (possibly extreme), nightmares, paresthesia, psychiatric disturbance, syncope, tremor, weakness CV: Arrhythmias (bradycardia, tachycardia), chest pain, heart failure, hypotension, palpitations, peripheral edema EENT: Altered taste, blurred vision, dry mouth, epistaxis, gingival hyperplasia, nasal congestion, pharyngitis, sinusitis, tinnitus ENDO: Gynecomastia, hyperglycemia GI: Anorexia, constipation, diarrhea, dyspepsia, elevated liver function test results, hepatitis, nausea, vomiting GU: Dysuria, nocturia, polyuria, sexual dysfunction, urinary frequency HEME: Anemia, leukopenia, positive Coombs' test, thrombocytopenia MS: Joint stiffness, muscle cramps RESP: Chest congestion, cough, dyspnea, respiratory tract infection, wheezing SKIN: Dermatitis, diaphoresis, erythema multiforme, flushing, photosensitivity, pruritus, rash, urticaria Nursing Considerations When starting and stopping nifedipine therapy, taper it, as prescribed, over 7 to 14 days. For closely monitored hospitalized patient with angina, dosage may be increased 10 mg every 4 to 6 hours to control chest pain. Because of drug's negative inotropic effect on some patients, frequently monitor heart rate and rhythm and blood pressure in patients who take a beta blocker or have heart failure or significant left ventricular dysfunction. Monitor fluid intake and output and daily weight; fluid retention may lead to heart failure. Also assess for signs of heart failure, such as crackles, dyspnea, jugular vein distention, peripheral edema, and weight gain. Patient Teaching Instruct patient to swallow E.R. tablets whole, not to crush, chew, or break them. Inform her that their empty shells may appear in stool. Urge patient to take nifedipine exactly as prescribed, even when she's feeling well. Advise her to notify prescriber if she misses two or more doses. Urge patient not to take drug within 1 hour of a high-fat meal or grapefruit. Urge her not to alter the amount of grapefruit in her diet without consulting prescriber. WARNING Caution patient against stopping nifedipine abruptly because angina or dangerously high blood pressure could result. Teach patient how to measure her pulse rate and blood pressure, and advise her to call prescriber if they drop below accepted levels. Suggest that she keep a log of weekly measurements and take it to follow-up visits. Instruct patient to notify prescriber immediately about chest pain, difficulty breathing, ringing in ears, and swollen gums. Advise patient to avoid hazardous activities until drug's CNS effects are known. Urge patient to avoid alcoholic beverages because they may worsen dizziness, drowsiness, and hypotension. Teach patient to minimize constipation by increasing her intake of fluids, if allowed, and dietary fiber. Emphasize the need to comply with prescribed lifestyle changes, such as alcohol moderation, low-fat or low-sodium diet, regular exercise, smoking cessation, stress reduction, and weight reduction. Stress the need for good oral hygiene and regular dental visits. Caution patient that hot tubs, saunas, and prolonged hot showers may cause dizziness and fainting. Advise patient to avoid prolonged sun exposure and to wear sunscreen outdoors.

Spironolactone

Aldactone, Novospiroton (CAN) Class, Category, and Schedule Chemical class: Aldosterone antagonist Therapeutic class: Aldosterone antagonist, antihypertensive, diagnostic aid for primary hyperaldosteronism, diuretic Pregnancy category: Not rated Indications and Dosages To treat edema cause by heart failure, hepatic cirrhosis, or nephrotic syndrome Tablets Adults. Initial: 25 to 200 mg daily in divided doses b.i.d. to q.i.d. for at least 5 days. Maintenance: 75 to 400 mg daily in divided doses b.i.d. to q.i.d. Maximum: 400 mg daily. Children. Initial: 1 to 3 mg/kg daily as a single dose or in divided doses b.i.d. to q.i.d. for at least 2 wk; adjusted, as needed, after 5 days. Maximum: 3 times initial dose. To treat hypertension Tablets Adults. Initial: 50 to 100 mg daily as a single dose or in divided doses b.i.d. to q.i.d. for at least 2 wk; gradually adjusted every 2 wk, as needed, to control blood pressure, up to 200 mg daily. Maximum: 400 mg daily. Children. Initial: 1 to 3 mg/kg daily as a single dose or in divided doses b.i.d. to q.i.d. for at least 2 wk; adjusted, as needed, after 5 days. Maximum: 3 times initial dose. To aid in the diagnosis of primary hyperaldosteronism Tablets Adults. For long test, 400 mg daily in divided doses b.i.d. to q.i.d. for 3 to 4 wk; for short test, 400 mg daily in divided doses b.i.d. to q.i.d. for 4 days. To treat primary hyperaldosteronism Tablets Adults. 100 to 400 mg daily in divided doses b.i.d. to q.i.d. before surgery. Maximum: 400 mg daily. To substitute as therapy for diuretic-induced hypokalemia Tablets Adults. 25 to 100 mg daily as a single dose or in divided doses b.i.d. to q.i.d. Maximum: 400 mg daily. Route Onset Peak Duration P.O.* Unknown 2 to 3 days 2 to 3 days Mechanism of Action Normally, aldosterone attaches to receptors on the walls of distal convoluted tubule cells, causing sodium (Na+) and water (H20) reabsorption in the blood, as shown at left. Spironolactone competes with aldosterone for these receptors, thereby preventing sodium and water reabsorption and causing their excretion through the distal convoluted tubules, as shown below right. Increased urinary excretion of sodium and water reduces blood volume and blood pressure. Contraindications Acute renal insufficiency, anuria, hyperkalemia, hypersensitivity to spironolactone or its components Interactions Drugs ACE inhibitors, cyclosporine, other potassium-sparing diuretics, potassium-containing drugs, potassium supplements: Increased risk of hyperkalemia digoxin: Possibly increased half-life of digoxin exchange resins (sodium cycle), such as sodium polystyrene sulfonate: Increased risk of hypokalemia and fluid retention heparin, oral anticoagulants: Decreased anticoagulant effect of these drugs hypotension-producing drugs: Possibly potentiated antihypertensive or diuretic effect of spironolactone lithium: Possibly lithium toxicity NSAIDs, sympathomimetics: Decreased anti-hypertensive effect of spironolactone Foods low-salt milk, salt substitutes: Increased risk of hyperkalemia Adverse Reactions CNS: Dizziness, encephalopathy, fatigue, headache EENT: Increased intraocular pressure, nasal congestion, tinnitus, vision changes ENDO: Gynecomastia GI: Abdominal pain, anorexia, constipation, diarrhea, flatulence, nausea, vomiting GU: Impotence HEME: Aplastic anemia, neutropenia RESP: Cough, dyspnea MS: Arthralgia, back and leg pain, muscle weakness, myalgia Other: Hyperkalemia Nursing Considerations Be aware that for children or patients who have trouble swallowing, pharmacist may crush spironolactone tablets, mix with a flavored syrup, and dispense as a suspension. It's stable for 1 month when refrigerated. In diagnosing primary aldosteronism, the test is considered positive if patient's serum potassium level rises when spironolactone is given and falls when it's discontinued. Expect to evaluate patient's serum potassium level 1 week after spiraonolactone therapy begins, after each dosage adjustment, monthly for the first 3 months, quarterly for 1 year, and then every 6 months thereafter or as ordered. Notify prescriber if level exceeds 5 mEq/L or patient's renal function deteriorates (serum creatinine level exceeding 4 mg/ dl). If patient has severe heart failure, follow closely because hyperkalemia may be fatal in such patients. Evaluate spironolactone's effectiveness by assessing blood pressure and edema. Stop drug for several days, as prescribed, before patient undergoes adrenal vein catheterization to measure serum aldosterone level and plasma renin activity. Patient Teaching Instruct patient to take spironolactone with meals or milk. If patient can't swallow tablets, mention that pharmacist can crush and mix them with a flavored syrup as a suspension. Teach patient who takes spironolactone for hypertension how to measure his blood pressure. Urge him to monitor it regularly and report pressure greater than 140 mm Hg systolic or 90 mm Hg diastolic to prescriber. Caution patient that he may experience dizziness during spironolactone therapy if fluid balance is altered.

naproxen sodium

Aleve, Anaprox, Anaprox DS, Apo-Napro-Na (CAN), Naprelan, Naprosyn-SR (CAN), Novo-Naprox Sodium (CAN) Class and Category Chemical class: Propionic acid derivative Therapeutic class: Analgesic, anti-inflammatory, antipyretic Pregnancy category: C Indications and Dosages To relieve mild to moderate musculo-skeletal inflammation, including ankylosing spondylitis, osteoarthritis, and rheumatoid arthritis Delayed-release tablets, oral suspension,tablets (naproxen) Adults. 250 to 500 mg b.i.d. Maximum: 1,500 mg daily for limited periods, as prescribed. E.R.tablets (naproxen sodium) Adults. 750 to 1,000 mg daily. Maximum: 1,500 mg daily. Tablets (naproxen sodium) Adults. 275 to 550 mg b.i.d. Maximum: 1,650 mg daily for limited periods, as prescribed. Suppositories (naproxen sodium) Adults. 500 mg at bedtime in addition to daytime P.O. administration. Maximum: 1,500 mg daily (P.O. and suppository combined). To relieve symptoms of juvenile rheumatoid arthritis and other inflammatory conditions in children Oral suspension,tablets (naproxen) Children. 10 mg/kg daily in divided doses b.i.d. To relieve symptoms of acute gouty arthritis Delayed-release tablets, oral suspension,tablets (naproxen) Adults. Initial: 750 mg, then 250 mg every 8 hr until symptoms subside. E.R.tablets (naproxen sodium) Adults. Initial: 1,000 to 1,500 mg on day 1; then 1,000 mg daily until symptoms subside. Maximum: 1,500 mg daily. Tablets (naproxen sodium) Adults. Initial: 825 mg, then 275 mg every 8 hr until symptoms subside. To relieve mild to moderate pain, including acute tendinitis and bursitis, arthralgia, dysmenorrhea, and myalgia Delayed-release tablets (naproxen) Adults. Initial: 1,000 mg daily. Maximum: 1,500 mg daily. E.R.tablets (naproxen sodium) Adults. Initial: 1,100 mg daily, increased as prescribed. Maximum: 1,500 mg daily. Oral suspension,tablets (naproxen) Adults. Initial: 500 mg, then 250 mg every 6 to 8 hr, p.r.n. Maximum: 1,250 mg daily. Tablets (naproxen sodium) Adults. Initial: 550 mg, then 275 mg every 6 to 8 hr, p.r.n. Maximum: 1,375 mg daily. To relieve fever and mild to moderate musculoskeletal inflammation or pain Tablets (OTC naproxen sodium) Adults. 220 mg every 8 to 12 hr; or 440 mg and 220 mg 12 hr later. Maximum: 660 mg daily for 10 days unless directed otherwise. Route Onset Peak Duration P.O. (naproxen)* 1 hr† 2 to 4 hr†‡ 7 to 12 hr† P.O. (naproxen sodium)* 30 min† 1 hr†‡ 7 to 12 hr† Mechanism of Action Blocks cyclooxygenase, the enzyme needed to synthesize prostaglandins, which mediate the inflammatory response and cause local vasodilation, swelling, and pain. Thus, naproxen, an NSAID, reduces symptoms of inflammation and relieves pain. Antipyretic action probably stems from its effect on the hypothalamus, which increases peripheral blood flow, causing vasodilation and heat dissipation. Contraindications Angioedema, asthma, bronchospasm, nasal polyps, rhinitis, or urticaria induced by aspirin, iodides, or other NSAIDs; hypersensitivity to naproxen or its components Interactions Drugs ACE inhibitors: Decreased antihypertensive effects; increased risk of renal dysfunction acetaminophen: Increased risk of adverse renal effects with combined long-term use aluminum hydroxide or magnesium oxide antacids, cholestyramine, sucralfate: Possibly delayed absorption of naproxen anticoagulants, thrombolytics: Prolonged PT, increased risk of bleeding antihypertensives: Decreased effectiveness of antihypertensive aspirin: Decreased aspirin effectiveness from lowered plasma and peak aspirin levels beta blockers: Decreased antihypertensive effects of these drugs bone marrow depressants, such as aldesleukin and cisplatin: Increased risk of leukopenia and thrombocytopenia cefamandole, cefoperazone, cefotetan, plicamycin, valproic acid: Increased risk of hypoprothrombinemia and bleeding cimetidine: Altered blood naproxen level colchicine, glucocorticoids, other NSAIDs, potassium supplements, salicylates: Increased GI irritability and bleeding cyclosporine, gold compounds, nephrotoxic drugs: Increased risk of nephrotoxicity digoxin: Increased blood digoxin level and risk of digitalis toxicity diuretics: Decreased diuretic effectiveness furosemide: Decreased natriuretic effect insulin, oral antidiabetic drugs: Increased effectiveness of these drugs; risk of hypoglycemia lithium: Increased risk of lithium toxicity methotrexate: Increased risk of methotrexate toxicity naproxen-containing products: Increased risk of toxicity phenytoin: Increased blood phenytoin level probenecid: Increased risk of naproxen toxicity Activities alcohol use, smoking: Increased risk of naproxen-induced GI ulceration Adverse Reactions CNS: Aseptic meningitis, chills, cognitive impairment, decreased concentration, depression, dizziness, dream disturbances, drowsiness, fever, headache, insomnia, light-headedness, malaise, seizures, stroke, vertigo CV: Edema, heart failure, hypertension, MI, palpitations, tachycardia, vasculitis EENT: Papilledema, papillitis, retrobulbar optic neuritis, stomatitis, tinnitus, vision or hearing changes ENDO: Hyperglycemia, hypoglycemia GI: Abdominal pain, anorexia, colitis, constipation, diarrhea, diverticulitis, dyspepsia, dysphagia, elevated liver function test results, esophagitis, flatulence, gastritis, gastroenteritis, gastroesophageal reflux disease, GI bleeding and ulceration, heartburn, hematemesis, hepatitis, indigestion, melena, nausea, pancreatitis, peptic ulceration, perforation of stomach or intestines, stomatitis, vomiting GU: Elevated serum creatinine level, glomerulonephritis, hematuria, infertility (in women), interstitial nephritis, menstrual irregularities, nephrotic syndrome, renal failure, renal papillary necrosis HEME: Agranulocytosis, anemia, aplastic anemia, eosinophilia, granulocytopenia, hemolytic anemia, leukopenia, neutropenia, pancytopenia, thrombocytopenia MS: Muscle weakness, myalgia RESP: Asthma, dyspnea, eosinophilic pneumonitis, respiratory depression SKIN: Alopecia, diaphoresis, ecchymosis, erythema multiforme, photosensitivity, pruritus, pseudoporphyria, purpura, rash, Stevens-Johnson syndrome, systemic lupus erythematosus, toxic epidermal necrolysis, urticaria Other: Anaphylaxis, angioedema, hyperkalemia Nursing Considerations Use naproxen with extreme caution in patients with a history of ulcer disease or GI bleeding because NSAIDs such as naproxen increase the risk of GI bleeding and ulceration. Expect to use naproxen for the shortest time possible in these patients. Be aware that serious GI tract ulceration, bleeding, and perforation may occur without warning symptoms. Elderly patients are at greater risk. To minimize risk, give drug with food. If GI distress occurs, withhold drug and notify prescriber immediately. Use naproxen cautiously in patients with hypertension, and monitor blood pressure closely. Drug may cause hypertension or worsen it. Because of naproxen's sodium content, watch for fluid retention. Rehydrate a dehydrated patient before giving drug. If patient has renal disease, monitor renal function closely during therapy. Naproxen isn't recommended for patients with advanced renal disease. WARNING Monitor patient closely for thrombotic events, including MI and stroke, because NSAIDs increase the risk. Monitor patient—especially if she's elderly or receiving long-term naproxen therapy—for less common but serious adverse GI reactions, including anorexia, constipation, diverticulitis, dysphagia, esophagitis, gastritis, gastroenteritis, gastroesophageal reflux disease, hemorrhoids, hiatal hernia, melena, stomatitis, and vomiting. Monitor liver function test results because, in rare cases, elevations may progress to severe hepatic reactions, including fatal hepatitis, liver necrosis, and hepatic failure. Monitor BUN and serum creatinine levels in elderly patients, patients taking diuretics or ACE inhibitors, and patients with heart failure, impaired renal function, or hepatic dysfunction; naproxen may cause renal failure. Monitor CBC for decreased hemoglobin and hematocrit because drug may worsen anemia. WARNING If patient has bone marrow suppression or is receiving treatment with an antineoplastic drug, monitor laboratory results (including WBC count), and watch for evidence of infection because anti-inflammatory and antipyretic actions of naproxen may mask signs and symptoms, such as fever and pain. Assess patient's skin regularly for signs of rash or other hypersensitivity reaction because naproxen is an NSAID and may cause serious skin reactions without warning, even in patients with no history of NSAID sensivitity. At first sign of reaction, stop drug and notify prescriber. Assess drug effectiveness in ankylosing spondylitis, as evidenced by decreased night pain, morning stiffness, and pain at rest; in osteoarthritis: decreased joint pain or tenderness and increased mobility, range of motion, and ability to perform daily activities; in rheumatoid arthritis: increased mobility and decreased joint swelling and morning stiffness; in acute gouty arthritis: decreased heat, pain, swelling, and tenderness in affected joints. Tell prescriber if patient complains of vision changes; patient may need ophthalmic exam. Patient Teaching Caution patient not to exceed recommended dosage because serious adverse reactions may occur. Tell patient to swallow delayed-release tablets whole and not to break, crush, or chew them. Advise patient to take drug with food to reduce GI distress. Tell patient to take drug with a full glass of water and to remain upright for 15 to 30 minutes after taking it to prevent drug from lodging in esophagus and causing irritation. Caution patient to avoid hazardous activities until drug's CNS effects are known. Urge patient to keep scheduled appointments with prescriber to monitor progress. Tell pregnant patient to avoid taking naproxen-containing products late in pregnancy. Advise against taking naproxen for more than 10 days without consulting prescriber. Explain that naproxen may increase the risk of serious adverse cardiovascular reactions; urge patient to seek immediate medical attention if signs or symptoms arise, such as chest pain, shortness of breath, weakness, and slurring of speech. Inform patient that naproxen may increase the risk of serious adverse GI reactions; stress the importance of seeking immediate medical attention for such signs and symptoms as epigastric or abdominal pain, indigestion, black or tarry stools, or vomiting blood or material that looks like coffee grounds. Alert patient to rare but serious skin reactions. Urge her to seek immediate medical attention for rash, blisters, itching, fever, or other indications of hypersensitivity.

zolpidem tartrate

Ambien, Ambien CR, Tovalt Class, Category, and Schedule Chemical class: Imidazopyridine derivative Therapeutic class: Antianxiety, sedative-hypnotic Pregnancy category: B Controlled substance schedule: IV Indications and Dosages To provide short-term treatment of insomnia Tablets, orally disintegrating tablets Adults. 10 mg at bedtime for 7 to 10 days. Maximum: 10 mg daily. E.R.tablets Adults. 12.5 mg immediately before at bedtime. Mechanism of Action May potentiate the effects of gamma-aminobutyric acid (GABA) and other inhibitory neurotransmitters. By binding to specific benzodiazepine receptors in the limbic and cortical areas of the CNS, zolpidem increases GABA's inhibitory effects, blocks cortical and limbic arousal, and preserves deep sleep (stages 3 and 4). Contraindications Hypersensitivity to zolpidem or its components, ritonavir therapy Interactions Drugs azole antifungals: Increased CNS activity and additive adverse effects of zolpidem barbiturates, chlorpromazine, general anesthetics, opioid agonists, other CNS depressants, phenothiazines, tramadol, tricyclic antidepressants: Possibly increased CNS depression and reduced psychomotor function bupropion: Increased blood zolpidem level, possibly visual hallucinations, loss of alertness desipramine, imipramine: Increased risk of visual hallucinations and reduced alertness flumazenil: Antagonized sedative effect haloperidol: Increased CNS depression nevirapine: Decreased blood zolpidem level rifabutin, rifampin: Increased zolpidem clearance selective serotonin-reuptake inhibitors: Increased risk of delusions, disorientation, and hallucinations Foods all foods: Increased time to peak blood zolpidem level, decreased effects of zolpidem Activities alcohol use: Increased CNS depression Adverse Reactions CNS: Amnesia, asthenia, ataxia, complex behaviors (such as sleep driving), confusion, dizziness, drowsiness, euphoria, hallucinations, headache, insomnia, lethargy, paradoxical CNS stimulation (including agitation, euphoria, hallucinations, hyperactivity, and nightmares), vertigo EENT: Diplopia, throat tightness, visual abnormality GI: Constipation, diarrhea, hiccups, indigestion, nausea, vomiting GU: UTI MS: Arthralgia, myalgia RESP: Dyspnea, upper respiratory infection Other: Anaphylaxis, angioedema, withdrawal symptoms Nursing Considerations Use zolpidem cautiously in patients with additional disorders because it isn't known if zolpidem therapy might aggravate these conditions. Administer zolpidem just before patient's bedtime because drug has a rapid onset of action. Expect patient to receive no more than a 1-month supply of zolpidem for outpatient therapy. WARNING If zolpidem is withdrawn abruptly (especially after prolonged therapy), monitor patient for withdrawal symptoms, such as abdominal cramps or discomfort, fatigue, flushing, inconsolable crying, light-headed-ness, nausea, nervousness, panic attack, rebound insomnia, and vomiting. Expect that zolpidem will produce anticonvulsant and muscle relaxant effects at high doses. If patient takes other CNS depressants, expect to reduce zolpidem dosage, as prescribed. WARNING Monitor patient closely for hypersensitivity reactions such as dyspnea, throat tightness, nausea, vomiting, and swelling. If present, discontinue zolpidem immediately, notify prescriber, and provide supportive care. Patient Teaching Caution patient to take drug exactly as prescribed and not to increase dosage unless directed by prescriber. Advise patient taking extended-release form to swallow tablet whole and not to break, crush, or chew it. Advise patient taking orally disintegrating form to place tablet on tongue, let it dissolve, and then swallow with saliva or, if patient prefers, with water. Instruct patient to take zolpidem immediately before going to bed, on an empty stomach. Advise patient to notify prescriber immediately about abdominal cramps or discomfort, fatigue, flushing, inconsolable crying, light-headedness, nausea, nervousness, panic attack, and vomiting. Instruct patient to stop taking zolpidem and seek emergency care if she has trouble breathing, throat tightness, nausea, vomiting, or abnormally swelling. Advise patient that zolpidem may produce abnormal behaviors during sleep, such as driving a car, eating, talking on the phone, or having sex without any recall of the event. If patient's family notices any such behavior or if patient sees evidence of such behavior upon awakening, the prescriber should be notified.

disulfiram

Antabuse Class and Category Chemical class: Thiuram derivative Therapeutic class: Alcohol abuse deterrent Pregnancy category: Not rated Indications and Dosages As adjunct to maintain sobriety in treatment of chronic alcoholism Tablets Adults. Initial: Up to 500 mg daily for 1 to 2 wk. Maintenance: 125 to 500 mg daily. Maximum: 500 mg daily. Route Onset Peak Duration P.O. In 1 to 2 hr Unknown Up to 14 days Mechanism of Action Interferes with the enzyme responsible for hepatic oxidation of acetaldehyde to acetate, which occurs during alcohol catabolism. Ingestion of even a small amount of alcohol after taking disulfiram raises the blood acetaldehyde level to 5 to 10 times normal. Disulfiram doesn't alter the rate of alcohol elimination. Its major metabolite, diethyldithiocarbamate, inhibits nor-epinephrine synthesis and may be responsible for the drug's hypotensive effect. Contraindications Alcohol intoxication; coronary artery occlusion; hypersensitivity to disulfiram, its components, rubber, pesticides, or fungicides; psychosis; recent use of alcohol, alcohol-containing preparations, metronidazole, or paraldehyde; severe myocardial disease Interactions Drugs alfentanil: Decreased plasma clearance and prolonged duration of action of alfentanil amoxicillin-clavulanate, bacampicillin: Possibly disulfiram-alcohol reaction ascorbic acid: Possibly interference with disulfiram-alcohol reaction CNS depressants: Possibly increased CNS depressant effects of either drug isoniazid: Increased risk of additive neuro-toxic effect of disulfiram; possibly increased adverse CNS effects metronidazole: Risk of CNS toxicity, resulting in confusion and psychosis oral anticoagulants: Possibly increased anticoagulant effects paraldehyde: Decreased paraldehyde metabolism, increased blood paraldehyde level phenytoin: Possibly increased blood phenytoin level and risk of phenytoin toxicity tricyclic antidepressants: Possibly temporary delirium Foods caffeine: Possibly increased cardiovascular and CNS effects of caffeine Activities alcohol use: Disulfiram-alcohol reaction (if used within 14 days of disulfiram therapy) Adverse Reactions CNS: Drowsiness, headache, peripheral neuropathy, psychotic reaction, tiredness EENT: Blurred vision, garlic or metallic taste, optic atrophy, optic neuritis GU: Impotence SKIN: Rash Nursing Considerations Know that disulfiram is given only to patients who are highly motivated to stop drinking and who are receiving psychotherapy or substance abuse counseling. Be aware that alcohol content of patient's other drugs should be checked before starting therapy. WARNING Never give drug to patient without her knowledge or who is intoxicated. If needed, crush tablet and mix with fluids before administration. Don't give drug within 14 days of patient's ingestion of a substance that contains alcohol. Expect alcohol ingestion during disulfiram therapy to produce a severe reaction that lasts from 30 minutes to several hours. Symptoms may include angina, anxiety, blurred vision, confusion, diaphoresis, dyspnea, heart failure, hypotension, nausea, palpitations, sinus tachycardia, syncope, thirst, throbbing headache, throbbing in neck, vertigo, vomiting, and weakness. A deep sleep usually follows. WARNING Be aware that ingestion of three or more alcoholic beverages with a disul-firam dose greater than 500 mg daily may cause respiratory depression, arrhythmias, and cardiac arrest. If patient takes phenytoin, monitor blood phenytoin level before and during disulfiram therapy, and adjust dosage of either drug as prescribed. Interactions may not occur if disulfiram therapy starts before phenytoin therapy. A subtherapeutic phenytoin level may result if disulfiram therapy stops. If patient takes an oral anticoagulant, monitor PT before and during disulfiram therapy, and adjust anticoagulant dosage as prescribed. Drug interactions may not occur if disulfiram therapy starts before warfarin therapy. If disulfiram therapy stops, be prepared to adjust warfarin dosage to avoid loss of hypoprothrombinemic effects. Expect some adverse reactions, such as drowsiness, headache, and impotence, to subside over time or with a brief dosage reduction. Because one-fifth of a disulfiram dose may stay in the body for 1 week or longer, know that alcohol ingestion may continue to produce unpleasant symptoms for up to 2 weeks after therapy stops. Expect therapy to last months to years, depending on patient's ability to abstain from alcohol. Patient Teaching Teach patient's household and family members about precautions needed and risks associated with disulfiram therapy. Inform patient that drug doesn't cure alcoholism but does help deter alcohol consumption. If patient reports daytime drowsiness, advise her to take drug in the evening. Warn patient to avoid alcohol-containing substances, such as vinegar, cough syrup, and sauces, during therapy because a disulfiram-alcohol reaction may occur after ingesting as little as 15 ml of 100-proof alcohol. Encourage patient to avoid alcohol-containing liniments and lotions as well. Teach patient what to expect if a disulfiram-alcohol reaction occurs. Inform her that a deep sleep usually follows the reaction. Advise patient that a reaction can occur up to 14 days after therapy stops and that a severe reaction may cause respiratory depression, arrhythmias, and cardiac arrest. Instruct patient to carry medical identification that indicates drug, describes possible reactions, and lists someone to notify in case of emergency.

morphine

Astramorph PF, Avinza, DepoDur, Du-ramorph, Epimorph (CAN), Kadian, M-Eslon (CAN), Morphine Extra-Forte (CAN), Morphine Forte (CAN), Morphine H.P. (CAN), Morphitec (CAN), MS Contin, MSIR, MS/L, MS/L Concentrate, MS/S, OMS Concentrate, Oramorph SR, Rescudose, RMS Uniserts, Roxanol, Rox-anol 100, Roxanol UD, Statex (CAN) Class, Category, and Schedule Chemical class: Phenanthrene derivative Therapeutic class: Analgesic Pregnancy category: C Controlled substance schedule: II Indications and Dosages To relieve acute or chronic moderate to severe pain; as adjunct to treat pulmonary edema caused by left-sided heart failure; to supplement general, local, or regional anesthesia Capsules, oral solution, syrup, tablets Adults. Initial: 10 to 30 mg every 4 hr, p.r.n. Children. Individualized dosage based on patient's age, size, and need. I.V. infusion Adults. Initial: 15 mg (or more) followed by 0.8 to 10 mg/hr, increased as needed for effectiveness. Maintenance: 0.8 to 80 mg/hr. Children.Neonates. 0.01 to 0.04 mg/kg/hr postoperatively, 0.025 to 2.6 mg/kg/hr for severe chronic cancer pain, or 0.03 to 0.15 mg/kg/hr for sickle cell crisis. Initial: 0.010 mg/kg/hr (10 mcg/ kg/hr) postoperatively. Maintenance: 0.015 to 0.02 mg/kg/hr (15 to 20 mcg/kg/hr). I.V. injection Adults. 2.5 to 15 mg injected slowly. Children. 0.5 to 0.1 mg/kg given slowly. I.M. or subcutaneous injection Adults. Initial: 10 mg (based on 70-kg [154-lb] adult) every 4 hr. Maintenance: 5 to 20 mg. Children. Initial: 0.1 to 0.2 mg/kg every 4 hr. Maximum: 15 mg/dose. Epidural infusion (preservative-free) Adults. Initial: 2 to 4 mg/24 hr, increased by 1 to 2 mg/24 hr, as directed. Epidural injection (preservative-free) Adults. Initial: 5 mg into lumbar region. If pain isn't relieved after 1 hr, 1- to 2-mg doses given at appropriate intervals to relieve pain. Maximum: 10 mg/24 hr. Intrathecal injection (preservative-free) Adults. 0.2 to 1 mg as a single dose. Suppositories Adults. 10 to 30 mg every 4 hr, p.r.n. Children. Individualized dosage based on patient's age, size, and need. To relieve chronic moderate to severe pain that requires opioids for more than a few days E.R. capsules Adults. Individualized dosage given every 12 to 24 hr. E.R.tablets Adults. 30 mg every 12 hr. Dosage increased based on patient's response. To relieve MI pain I.V. injection Adults. 1 to 4 mg by slow I.V. injection. Repeated up to every 5 min, if needed. Maximum: 2 to 15 mg. To provide preoperative analgesia I.M. or subcutaneous injection Adults. 5 to 20 mg given 45 to 60 min before surgery. Children. 0.05 to 0.1 mg/kg given 45 to 60 min before surgery. Maximum: 10 mg. To provide analgesia during labor I.M. or subcutaneous injection Adults. 10 mg, with subsequent doses based on patient's response. Mechanism of Action Binds with and activates opioid receptors (mainly mu receptors) in brain and spinal cord to produce analgesia and euphoria. Contraindications For all drug forms: Asthma, hypersensitivity to morphine or its components, labor (premature delivery), prematurity (in infants), respiratory depression, upper airway obstruction For oral solution: Acute abdominal disorders, acute alcoholism, alcohol withdrawal syndrome, arrhythmias, brain tumor, head injuries, heart failure caused by chronic lung disease, increased intracranial or cerebrospinal pressure, recent biliary tract surgery, respiratory insufficiency, seizure disorders, severe CNS depression, surgical anastomosis, use within 14 days of an MAO inhibitor For I.V., I.M., or subcutaneous injection: Acute alcoholism, alcohol withdrawal syndrome, arrhythmias, brain tumor, heart failure caused by chronic lung disease, seizure disorders For epidural or intrathecal injection: Anticoagulant therapy, bleeding tendency, injection site infection, parenteral corticosteroid treatment (or other treatment or condition that prohibits drug administration by intrathecal or epidural route) within 2 weeks Interactions Drugs amitriptyline, clomipramine, nortriptyline: Increased CNS and respiratory depression anticholinergics: Possibly severe constipation leading to ileus, urine retention antidiarrheals (such as loperamide and paregoric): CNS depression, possibly severe constipation antihistamines, chloral hydrate, glutethimide, MAO inhibitors, methocarbamol: Increased CNS and respiratory depressant effects of morphine antihypertensives, hypotension-producing drugs: Increased hypotension, risk of orthostatic hypotension buprenorphine: Decreased therapeutic effects of morphine, increased respiratory depression, possibly withdrawal symptoms cimetidine: Increased analgesic and CNS and respiratory depressant effects of morphine CNS depressants (antiemetics, general anesthetics, hypnotics, phenothiazines, sedatives, tranquilizers): Possibly coma, hypotension, respiratory depression, severe sedation diuretics: Decreased diuretic efficacy hydroxyzine: Increased analgesic, CNS depressant, and hypotensive effects of morphine metoclopramide: Possibly antagonized metoclopramide effect on GI motility mixed agonist-antagonist analgesics: Possibly withdrawal symptoms naloxone: Antagonized analgesic and CNS and respiratory depressant effects of morphine, possibly withdrawal symptoms naltrexone: Possibly induction or worsening of withdrawal symptoms if morphine given within 7 to 10 days before naltrexone neuromuscular blockers: Increased or prolonged respiratory depression opioid analgesics (such as alfentanil and sufentanil): Increased CNS and respiratory depression, increased hypotension zidovudine: Decreased zidovudine clearance Activities alcohol use: Increased CNS and respiratory depression, increased hypotension Adverse Reactions CNS: Amnesia, anxiety, coma, confusion, decreased concentration, delirium, delusions, depression, dizziness, drowsiness, euphoria, fever, hallucinations, headache, insomnia, lethargy, light-headedness, malaise, psychosis, restlessness, sedation, seizures, syncope, tremor, unarousable, unresponsiveness CV: Bradycardia, cardiac arrest, hypotension, orthostatic hypotension, palpitations, shock, tachycardia EENT: Blurred vision, diplopia, dry mouth, laryngeal edema or laryngospasm (allergic), miosis, nystagmus, rhinitis GI: Abdominal cramps or pain, anorexia, biliary tract spasm, constipation, diarrhea, dysphagia, elevated liver function test results, gastroesophageal reflux, hiccups, ileus and toxic megacolon (in patients with inflammatory bowel disease), intestinal obstruction, indigestion, nausea, vomiting GU: Decreased ejaculate potency, decreased libido, difficult ejaculation, impotence, menstrual irregularities, oliguria, prolonged labor, urinary hesitancy, urine retention HEME: Anemia, leukopenia, thrombocytopenia MS: Arthralgia RESP: Apnea, asthma exacerbation, atelectasis, bronchospasm, depressed cough reflex, hypoventilation, pulmonary edema, respiratory arrest and depression, wheezing SKIN: Diaphoresis, flushing, pallor, pruritus, urticaria Other: Allergic reaction; anaphylaxis; facial edema; injection site edema, pain, rash, or redness; physical and psychological dependence; withdrawal symptoms Nursing Considerations Use cautiously in patients about to undergo surgery of the biliary tract and patients with acute pancreatitis secondary to biliary tract disease because morphine may cause spasm of the sphincter of Oddi. Store morphine sulfate at room temperature. Before giving morphine, make sure opioid antagonist and equipment for giving oxygen and controlling respiration are available. Before therapy, assess patient's drug use, including all prescription and OTC drugs. Expect prescriber to start patient who has never received opioids on immediate-release form and then switch to E.R. form if therapy must last longer than a few days. Give oral form with food or milk to minimize adverse GI reactions, if needed. Solution can be mixed with fruit juice to improve taste. If needed, open E.R. capsules and sprinkle contents on applesauce (at room temperature or cooler) just before giving to patient. Make sure patient doesn't chew or crush capsules or dissolve capsule's pellets in his mouth. Be aware that E.R. forms of morphine aren't interchangeable. Discard injection solution that is discolored or darker than pale yellow or that contains precipitates that don't dissolve with shaking. WARNING Don't use highly concentrated solutions (such as 10 to 25 mg/ml) for single-dose I.V., I.M., or subcutaneous administration. These solutions are intended for use in continuous, controlled microinfusion devices. For direct I.V. injection, dilute appropriate dose with 4 to 5 ml of sterile water for injection. Inject 2.5 to 15 mg directly into tubing of free-flowing I.V. solution over 4 to 5 minutes. Rapid I.V. injection may increase adverse reactions. For continuous I.V. infusion, dilute drug in D5W and administer with infusion-control device. Adjust dose and rate based on patient response, as prescribed. Avoid I.M. route for long-term therapy because of injection site irritation. During subcutaneous injection, take care to avoid injecting drug intradermally. For intrathecal injection, expect prescriber to give no more than 2 ml of 0.5-mg/ml solution or 1 ml of 1-mg/ml solution. Expect intrathecal dosage to be about onetenth of epidural dosage. If rectal suppository is too soft to insert, chill it in refrigerator for 30 minutes or run wrapped suppository under cold tap water. WARNING Monitor respiratory and cardiovascular status carefully and frequently during morphine therapy. Be alert for respiratory depression and hypotension. Monitor patient with seizure disorder for increased seizure activity because morphine may worsen the disorder. Monitor patient for excessive or persistent sedation; dosage may need to be adjusted If patient is receiving a continuous morphine infusion, watch for and notify prescriber about new neurologic signs or symptoms. Inflammatory masses (such as granulo-mas) have caused serious neurologic reactions, including paralysis. Expect morphine to cause physical and psychological dependence; watch for drug tolerance and withdrawal symptoms, such as body aches, diaphoresis, diarrhea, fever, piloerection, rhinorrhea, sneezing, and yawning. If tolerance to morphine develops, expect prescriber to increase dosage. Morphine may have a prolonged duration and cumulative effect in patients with impaired hepatic or renal function. It also may prolong labor by reducing strength, duration, and frequency of uterine contractions. When discontinuing morphine in patients receiving more than 30 mg daily, expect prescriber to reduce daily dose by about one-half for 2 days and then by 25% every 2 days thereafter until total dose reaches initial amount recommended for patients who haven't received opioids (15 to 30 mg daily). This regimen minimizes the risk of withdrawal symptoms. Patient Teaching Instruct patient to take morphine exactly as prescribed and not to change dosage without consulting prescriber. Explain that patient may take tablets or capsules with food or milk to relieve GI distress and may mix oral solution with juice to improve taste. Urge patient not to break, chew, or crush E.R. capsules and tablets to avoid rapid release and, possibly, toxicity. For patient who has difficulty swallowing, suggest that he open E.R. capsules and sprinkle contents on food or liquids. Urge him to take drug immediately and not let capsule contents dissolve in his mouth. Instruct patient to moisten rectal suppository before inserting it. Urge patient to avoid alcohol and other CNS depressants during morphine therapy. Advise patient to avoid potentially hazardous activities during morphine therapy. Tell patient to change positions slowly to minimize the orthostatic hypotension. Instruct patient to notify prescriber about worsening or breakthrough pain. Inform patient that morphine may be habit-forming. Urge him to notify prescriber if he experiences anxiety, decreased appetite, excessive tearing, irritability, muscle aches or twitching, rapid heart rate, or yawning. Advise female patient to notify prescriber if she becomes pregnant. Regular morphine use during pregnancy may cause physical dependence in fetus and withdrawal in neonate.

amlodopine besylate

Norvasc Class and Category Chemical class: Dihydropyridine Therapeutic class: Antianginal, antihypertensive Pregnancy category: C Indications and Dosages To control hypertension TABLETS Adults. Initial: 5 mg daily, increased gradually over 10 to 14 days, as needed. Maximum: 10 mg daily. To treat chronic stable angina and Prinzmetal's (variant) angina TABLETS Adults. 5 to 10 mg daily. Route Onset Peak Duration P.O. Unknown 6-12 hr 24 hr Mechanism of Action Binds to dihydropyridine and nondihydropyridine cell membrane receptor sites on myocardial and vascular smooth-muscle cells and inhibits influx of extracellular calcium ions across slow calcium channels. This decreases intracellular calcium level, inhibiting smooth-muscle cell contractions and relaxing coronary and vascular smooth muscles, decreasing peripheral vascular resistance, and reducing systolic and diastolic blood pressure. Decreased peripheral vascular resistance also decreases myocardial workload, oxygen demand, and possibly angina. Also, by inhibiting coronary artery muscle cell contractions and restoring blood flow, drug may relieve Prinzmetal's angina. Contraindications Hypersensitivity to amlodipine or its components Interaction DRUGS beta blockers: Possibly excessive hypotension CYP3A4 inhibitors such as diltiazem, ketoconazole, itraconazole, and ritonavir: Possible increased blood amlodipine level fentanyl: Increased risk of severe hypotension and increased fluid volume requirements during surgery simvastatin: Increased exposure to simvastatin Adverse Reactions CNS: Anxiety, dizziness, fatigue, headache, lethargy, light-headedness, paresthesia, somnolence, syncope, tremor CV: Arrhythmias, chest pain, hypotension, palpitations, peripheral edema EENT: Dry mouth, gingival hyperplasia, pharyngitis ENDO: Hot flashes GI: Abdominal cramps, abdominal pain, anorexia, constipation, diarrhea, dysphagia, elevated hepatic enzymes, esophagitis, flatulence, indigestion, jaundice, nausea, pancreatitis, vomiting GU: Decreased libido, impotence, urinary frequency MS: Myalgia RESP: Dyspnea SKIN: Dermatitis, flushing, rash Other: Weight loss Nursing Considerations Use amlodipine cautiously in patients with heart block, heart failure, impaired renal function, hepatic disorder, or severe aortic stenosis. Monitor patient with impaired hepatic function closely because amlodipine is extensively metabolized by the liver, and expect to titrate dosage slowly when administering drug to patients with severe hepatic impairment. Monitor blood pressure while adjusting dosage, especially in patients with heart failure or severe aortic stenosis because symptomatic hypotension may occur. Assess patient frequently for chest pain when starting or increasing the dose of amlodipine, because worsening of angina or an acute myocardial infarction can occur, especially in patients with severe obstructive coronary artery disease. PATIENT TEACHING Tell patient to take missed dose as soon as remembered and next dose in 24 hours. Tell patient to immediately notify prescriber of dizziness, arm or leg swelling, difficulty breathing, hives, or rash. Suggest taking amlodipine with food to reduce GI upset. Advise patient to have blood pressure checked routinely for possible hypotension.

lithium carbonate

Carbolith (CAN), Duralith (CAN), Eskalith, Eskalith CR, Lithane, Lithizine (CAN), Lithobid, Lithonate, Lithotabs

verapamil hydrochloride

Calan SR, Isoptin SR, Verelan Class and Category Chemical class: Phenylalkylamine derivative Therapeutic class: Antianginal, antiarrhythmic, antihypertensive Pregnancy category: C Indications and Dosages To treat chronic angina pectoris Tablets (verapamil) Adults and adolescents age 15 and over. Initial: 80 to 120 mg t.i.d., increased every day or wk, as needed and prescribed. Maximum: 480 mg daily in divided doses. Infants and children up to age 15. 4 to 8 mg/ kg daily in divided doses. To manage hypertension E.R. Capsules (verapamil hydrochloride) Adults and adolescents. Initial: 240 mg daily, increased every day or wk, as needed and prescribed. Maximum: 480 mg daily. E.R.Tablets (verapamil hydrochloride) Adults and adolescents. Initial: 180 mg daily, increased every day or wk, as needed and prescribed, according to following schedule: 240 mg daily in the morning; 180 mg every 12 hr or 240 mg in the morning and 120 mg in the evening; then 240 mg every 12 hr. Maximum: 480 mg daily in divided doses. Tablets (verapamil) Adults and adolescents age 15 and over. Ini- tial: 80 to 120 mg t.i.d., increased every day or wk, as needed and prescribed. Maximum: 480 mg daily in divided doses. Infants and children up to age 15. 4 to 8 mg/ kg daily in divided doses. To prevent or treat supraventricular tachycardia Tablets (verapamil) Adults and adolescents age 15 and over. Initial: 80 to 120 mg t.i.d., increased every day or wk, as needed and prescribed. Maximum: 480 mg daily in divided doses. I.V. Injection (verapamil hydrochloride) Adults and adolescents age 15 and over. Initial: 5 to 10 mg slowly over 2 min; then 10 mg, as prescribed, if response isn't adequate after 30 min. Children ages 1 to 15. Initial: 100 to 300 mcg/kg slowly over 2 min, up to maximum of 5 mg; then 10 mg, as prescribed, if response isn't adequate after 30 min. Infants up to age 1. Initial: 100 to 200 mcg/ kg slowly over 2 min. Route Onset Peak Duration P.O. 1 to 2 hr 30 to 90 min 6 to 8 hr P.O. (E.R.) 1 to 2 hr 30 to 90 min Unknown I.V. 1 to 5 min 3 to 5 min 10 min to 6 hr Mechanism of Action Inhibits calcium movement into coronary and vascular smooth-muscle cells by blocking slow calcium channels in cell membranes. The resulting decrease in the intracellular calcium level has the following effects: inhibits smooth-muscle cell contractionsdecreases myocardial oxygen demand by relaxing coronary and vascular smooth muscle, reducing peripheral vascular resistance, and decreasing systolic and diastolic pressuresslows AV conduction time and prolongs AV nodal refractorinessinterrupts reentry circuit in AV nodal reentrant tachycardias. Incompatibilities Don't mix I.V. verapamil with albumin, amphotericin B injection, hydralazine hydrochloride injection, nafcillin, or sulfamethoxazole and trimethoprim injection. Solutions with pH above 6.0 cause precipitation. in Contraindications Cardiogenic shock, concomitant use of beta blockers (with I.V. verapamil), hypersensitivity to verapamil or its components, hypotension, severe heart failure unless secondary to supraventricular tachycardia that responds to verapamil, severe left ventricular dysfunction, sick sinus syndrome or second- or third-degree heart block unless artificial pacemaker is in place, ventricular tachycardia (with I.V. verapamil) Interactions Drugs alpha blockers, antihypertensives, general anesthetics (hydrocarbon), prazosin: Hypotensive effects aspirin: Increased bleeding time beta blockers: Increased risk of heart failure, hypotension, and severe bradycardia calcium supplements: Decreased response to verapamil carbamazepine, cyclosporine, theophylline, valproate: Increased risk of toxicity from these drugs cimetidine: Decreased metabolism and increased blood level of verapamil dantrolene: Increased risk of hyperkalemia and myocardial depression digoxin: Increased blood digoxin level and risk of digitalis toxicity disopyramide, flecainide: Additive negative inotropic effects erythromycin, ritonavir: Increased blood verapamil level lithium: Increased risk of neurotoxicity neuromuscular blockers: Prolonged recovery from neuromuscular blockade NSAIDs, sympathomimetics: Decreased antihypertensive effect of verapamil phenobarbital: Increased verapamil clearance procainamide: Increased Q-T interval, additive negative inotropic effects protein-bound drugs (hydantoins, salicylates, sulfonamides, sulfonylureas, and warfarin and other oral anticoagulants): Altered blood levels of these drugs quinidine: Increased risk of quinidine toxicity, increased Q-T interval, additive negative inotropic effects rifampin: Decreased bioavailability of oral verapamil telithromycin: Increased risk of bradyar-rhythmias, hypotension, and lactic acidosis Foods grapefruit juice: Increased concentrations of verapamil Activities alcohol use: Increased blood alcohol level and prolonged CNS effects Adverse Reactions CNS: Confusion, CVA, disequilibrium, dizziness, extrapyramidal reactions, fatigue, headache, insomnia, paresthesia, psychosis, shakiness, somnolence CV: Angina, AV conduction disorders, bradycardia, claudication, heart failure, hypotension, peripheral edema, tachycardia GI: Constipation, elevated liver function test results, nausea GU: Galactorrhea, menstrual irregularities MS: Muscle spasms RESP: Dyspnea, pulmonary edema, wheezing SKIN: Flushing, rash Nursing Considerations Administer I.V. verapamil with compatible solutions, including Ringer's injection, D5W, or normal saline solution. Maintain continuous ECG monitoring and keep emergency resuscitative equipment and drugs readily available during I.V. therapy. Assess patient with hypertrophic cardiomyopathy for early development of hypotension and pulmonary edema because second-degree AV block and sinus arrest can result. Assess for bradycardia and hypotension, and notify prescriber if heart rate or blood pressure declines significantly. Be aware that disopyramide or flecainide shouldn't be given within 48 hours before or 24 hours after verapamil because additive negative inotropic effects can result. Institute measures to prevent constipation, including a high-fiber diet and a stool softener, as prescribed. Patient Teaching Instruct patient not to crush or chew verapamil E.R. tablets or capsules. Inform her that she may break E.R. tablets in half if necessary to aid swallowing. Direct patient to check her pulse rate before taking verapamil and to notify prescriber if it's below 50 beats/minute or as instructed by prescriber. Caution patient about possible dizziness and the need to avoid potentially hazardous activities until drug's CNS effects are known. Inform patient that adverse skin reactions may subside with continued use. Advise her to notify prescriber if rash persists. Encourage patient to increase dietary fiber intake to help prevent constipation. Advise her to notify prescriber if problem becomes persistent or severe.

acamprosate calcium

Campral Class and Category Chemical class: Synthetic endogenous amino acid homotaurine, gamma-aminobutyric acid (GABA) analogue Therapeutic class: Antialcoholic Pregnancy category: C Indications and Dosages To maintain abstinence from alcohol for alcohol-dependent patients who are abstinent at the start of treatment E.R. TABLETS Adults. 666 mg t.i.d. Route Onset Peak Duration P.O. Unknown 3-8 hr Unknown Mechanism of Action Chronic alcoholism may alter the balance between excitation and inhibition in neurons in the brain; acamprosate restores it. When the neurotransmitter gamma-aminobutyric acid (GABA) binds to its receptors in the CNS, it opens the chloride ion channel and releases chloride (Cl-) into the cell (below left), thereby reducing neuronal excitability by inhibiting depolarization. By interacting with GABA receptor sites, acamprosate prevents GABA from binding (below right). When glutamate binds to its receptors, it closes the chloride ion channel, increasing neuronal excitability by promoting depolarization (below left). This imbalance fosters a craving for alcohol. By interacting with glutamate receptor sites, acamprosate prevents glutamate from binding (below right). Contraindications Hypersensitivity to acamprosate or its components, severe hepatic (Child-Pugh class C) or renal impairment Interaction DRUGS antidepressants: Increased weight gain tetracyclines: Decreased absorption of tetracyclines Adverse Reactions CNS: Abnormal thinking, amnesia, anxiety, asthenia, chills, depression, dizziness, headache, insomnia, paresthesia, somnolence, suicidal ideation, syncope, tremor CV: Chest pain, hypertension, palpitations, peripheral edema, vasodilation EENT: Abnormal vision, dry mouth, pharyngitis, rhinitis, taste perversion GI: Abdominal pain, anorexia, constipation, diarrhea, flatulence, increased appetite, indigestion, nausea, vomiting GU: Acute renal failure, decreased libido, impotence HEME: Leukopenia, lymphocytosis, thrombocytopenia MS: Arthralgia, back pain, myalgia RESP: Bronchitis, cough, dyspnea SKIN: Diaphoresis, pruritus, rash Other: Flulike symptoms, infection, weight gain Nursing Considerations Acamprosate should start as soon as possible after patient has undergone alcohol withdrawal and achieved abstinence. Continue to give acamprosate even during periods of alcohol relapse. PATIENT TEACHING Instruct patient to take acamprosate exactly as prescribed, even if a relapse occurs, and to seek help for a relapse. Warn patient that acamprosate won't reduce symptoms of alcohol withdrawal if relapse occurs followed by cessation. Urge caregivers to monitor patient for evidence of depression (lack of appetite or interest in life, fatigue, excessive sleeping, difficulty concentrating) or suicidal tendencies because a small number of patients taking acamprosate have attempted suicide. Advise patient to use caution when performing hazardous activities until adverse CNS effects of drug are known. Tell female patient to notify prescriber if she is or intends to become pregnant while taking acamprosate; the drug may need to be stopped because fetal risks are unknown.

clonidine hydrochloride

Catapres, Dixarit (CAN), Duraclon Class and Category Chemical class: Imidazoline derivative Therapeutic class: Analgesic, antihyper-tensive Pregnancy category: C Indications and Dosages To manage hypertension Tablets Adults. Initial: 0.1 mg b.i.d. Dosage increased by 0.1 mg/wk to produce desired response. Maintenance: 0.2 to 0.6 mg daily in divided doses b.i.d. or t.i.d. Maximum: 2.4 mg daily. Transdermal patch Adults. Initial: 0.1-mg patch applied to hairless area of intact skin on upper arm or torso every 7 days. After 1 to 2 wk, if blood pressure isn't controlled, two 0.1-mg patches or one 0.2-mg patch applied to skin. Dosage adjusted, as needed, every 7 days. Maximum: Two 0.3-mg patches worn at same time. To treat severe hypertension Tablets Adults. 0.2 mg, then 0.1 mg every 1 hr until diastolic blood pressure reaches acceptable range or 0.8 mg have been administered. As adjunct to relieve severe pain (in cancer patients) that isn't adequately relieved by opioid analgesics alone Continuous epidural infusion Adults. Initial: 30 mcg/hr. Titrated up or down, if needed, depending on comfort. Maximum: 40 mcg/hr. Children old enough to tolerate placement and management of epidural catheter. Initial: 0.5 mcg/kg/hr. Then, titrated to achieve comfort. Route Onset Peak Duration P.O. 30 to 60 min 2 to 4 hr 8 hr Transdermal 2 to 3 days Unknown 7 days Mechanism of Action Stimulates peripheral alpha-adrenergic receptors in the CNS to produce transient vasoconstriction and then stimulates central alpha-adrenergic receptors in the brain stem to reduce peripheral vascular resistance, heart rate, and systolic and diastolic blood pressure. May produce analgesia by preventing transmission of pain signals to the brain at presynaptic and postjunctional alpha2-adrenoreceptors in the spinal cord. With epidural administration, clonidine produces analgesia in body areas innervated by the spinal cord segments in which the drug concentrates. Contraindications Anticoagulant therapy (epidural infusion); bleeding diathesis; hypersensitivity to clonidine or its components, including components of adhesive used in the transdermal patch; injection site infection (epidural infusion) Interactions Drugs barbiturates, other CNS depressants: Increased depressant effects of these drugs beta blockers, calcium channel blockers, digoxin: Additive effects, such as bradycardia and AV block; increased risk of worsened hypertensive response when clonidine is withdrawn (beta blockers only) diuretics, other antihypertensive drugs: Increased hypotensive effect epidural local anesthetics: Prolonged effects of epidural local anesthetics when used with epidural clonidine levodopa: Decreased levodopa effectiveness prazosin, tricyclic antidepressants: Decreased antihypertensive effect of clonidine Activities alcohol use: Enhanced CNS depressant effects of alcohol Adverse Reactions CNS: Agitation, depression, dizziness, drowsiness, fatigue, headache, malaise, nervousness, sedation, weakness CV: Chest pain, orthostatic hypotension EENT: Blurred vision, burning eyes, dry eyes and mouth GI: Constipation, mildly elevated liver function test results, nausea, vomiting GU: Decreased libido, impotence, nocturia SKIN: Rash Other: Weight gain, withdrawal symptoms Nursing Considerations Use clonidine cautiously in elderly patients, who may be more sensitive to its hypotensive effect. Monitor blood pressure and heart rate often during clonidine therapy. Expect transdermal clonidine to take 2 to 3 days to lower blood pressure. Remove patch before patient has an MRI to avoid possible burns at the patch site. Be aware that stopping drug abruptly can elevate serum catecholamine levels and cause such withdrawal symptoms as nervousness, agitation, headache, confusion, tremor, and rebound hypertension. Expect hypertension to return within 48 hours after drug is discontinued. Patient Teaching Advise patient to take drug exactly as prescribed and not to stop abruptly because withdrawal symptoms and severe hypertension may occur. Instruct patient to consult prescriber if dry mouth or drowsiness becomes a problem during oral clonidine therapy. To minimize these effects, prescriber may suggest taking most of dosage at bedtime. If a transdermal patch loosens during the 7-day application period, tell patient to place the adhesive overlay directly over the patch to ensure adhesion. Tell patient to rotate transdermal sites. Instruct patient to remove patch and place a fresh one on another site if skin irritation, redness, or rash develops at the patch site. Advise patient to fold used transdermal patch in half with adhesive sides together and discard it out of the reach of children. Because of possible sedation, advise patient to avoid potentially hazardous activities until drug's CNS effects are known. Advise men that libido may decrease. Instruct patient to report chest pain, dizziness with position changes, excessive drowsiness, rash, urine retention, and vision changes. As needed, tell patient to rise slowly to avoid hypotensive effects.

warfarin

Coumadin Class and Category Chemical class: Coumarin derivative Therapeutic class: Anticoagulant Pregnancy category: X Indications and Dosages To prevent or treat pulmonary embolism; recurrent MI; thromboembolic complications from atrial fibrillation, heart valve replacement, or MI; and venous thrombosis (and its extension) Tablets Adults. Initial: 2 to 5 mg daily for 2 to 4 days. Usual: 2 to 10 mg daily based on target PT and INR results. Maximum: Determined by target PT and INR results, as prescribed. I.V. injection Adults. Initial: 2 to 5 mg daily infused over 1 to 2 min. Usual: 2 to 10 mg daily infused over 1 to 2 min. Maximum: Determined by target PT and INR results, as prescribed. Route Onset Peak Duration P.O 24 hr 3 to 4 days 2 to 5 days I.V. Unknown 3 to 4 days 2 to 5 days Mechanism of Action Interferes with the liver's ability to synthesize vitamin K-dependent clotting factors, depleting clotting factors II (prothrombin), VII, IX, and X. This action, in turn, interferes with the clotting cascade. By depleting vitamin K-dependent clotting factors and interfering with the clotting cascade, warfarin prevents coagulation. Incompatibilities Don't mix warfarin in solution with amikacin sulfate, epinephrine hydrochloride, metaraminol tartrate, oxytocin, promazine hydrochloride, tetracycline hydrochloride, or vancomycin hydrochloride. in Contraindications Bleeding or bleeding tendencies; blood dyscrasias; cerebral or dissecting aneurysm; cerebrovascular hemorrhage; diverticulitis; eclampsia or preeclampsia; history of warfarin-induced necrosis; hypersensitivity to warfarin or its components; malignant or severe uncontrolled hypertension; malnutrition and emaciation; mental state or condition that leads to lack of patient cooperation; pericardial effusion; pericarditis; polyarthritis; pregnancy; prostatectomy; recent or planned neurosurgery, ophthalmic surgery, or spinal puncture; severe hepatic or renal disease Interactions Drugs acetaminophen, agrimony, aminoglycosides, amiodarone, androgens, argatroban, beta blockers, bivalirudin, capecitabine, cephalosporins, chloral hydrate, chloramphenicol, chlorpropamide, cimetidine, clofibrate, corticosteroids, cyclophosphamide, dextrothyroxine, diflunisal, disulfiram, erythromycin, ezetimibe, fluconazole, gemfibrozil, glucagon, hydantoins, ifosfamide, influenza virus vaccine, isoniazid, ketoconazole, lepirudin, loop diuretics, lovastatin, metronidazole, miconazole, mineral oil, moricizine, nalidixic acid, NSAIDs, omeprazole, penicillins, phenylbutazones, propafenone, propoxyphene, quinidine, quinine, quinolones, salicylates, streptokinase, sulfamethoxazole-trimethoprim, sulfinpyrazone, sulfonamides, tamoxifen, tetracyclines, thyroid hormones, urokinase, valdecoxib, vitamin E: Increased anticoagulant effect of warfarin, increased risk of bleeding aminoglutethimide, barbiturates, carbamazepine, cholestyramine, dicloxacillin, estrogens, ethchlorvynol, etretinate, glutethimide, griseofulvin, nafcillin, oral contraceptives, rifampin, spironolactone, sucralfate, thiazide diuretics, trazodone, vitamin C, vitamin K: Decreased anticoagulant effect of warfarin atorvastatin, pravastatin: Increased or decreased anticoagulant effect of warfarin herbal remedies (including bromelains, danshen, dong quai, garlic, ginkgo biloba, and ginseng): Increased anticoagulant effect of warfarin, increased risk of bleeding I.V. lipid emulsion, other medical products that contain soybean oil: Possibly decreased vitamin K absorption and increased anticoagulant effect of warfarin nicotine patch: Altered response to warfarin Foods certain multivitamins, enteral feedings, vitamin-K-rich foods: Decreased effects of warfarin Activities alcohol use: Increased risk of hypoprothrombinemia smoking, smoking cessation: Altered response to warfarin Adverse Reactions CNS: Coma, intracranial hemorrhage, loss of consciousness, syncope, weakness CV: Angina, chest pain, hypotension EENT: Epistaxis, intraocular hemorrhage GI: Abdominal cramps and pain, diarrhea, hepatitis, nausea, vomiting GU: Hematuria, vaginal bleeding (abnormal) HEME: Anemia, potentially fatal hemorrhage (from any tissue or organ) SKIN: Alopecia, ecchymosis, jaundice, petechiae, pruritus, purple-toe syndrome, tissue necrosis Other: Anaphylaxis Nursing Considerations Reconstitute parenteral warfarin just before administration with 2.7 ml of sterile water for injection to yield 2 mg/ml. Then administer slowly over 1 to 2 minutes through peripheral I.V. Expect to administer another parenteral anticoagulant, such as heparin or enoxaparin, with oral warfarin for at least 3 days, or until desired response occurs, before giving warfarin only. Avoid I.M. injections during warfarin therapy, if possible, because they can result in bleeding, bruising, and hematoma. Monitor INR (daily in acute care setting) and assess for therapeutic effects, as prescribed. Therapeutic INR levels are 2.0 to 3.0 for bioprosthetic heart valve, nonvalvular atrial fibrillation, and venous thromboembolism, and 2.5 to 3.5 after MI and for mechanical heart valve. Expect treatment to last up to 12 weeks for bioprosthetic heart valve, 1 to 3 months for nonvalvular atrial fibrillation or venous thromboembolism, and for rest of life after MI and for mechanical heart valve replacement. WARNING Be aware of the increased risk for intracranial hemorrhage if patient has cerebral ischemia (such as recent transient ischemic attack or minor ischemic CVA) and INR of 3 to 4.5. As prescribed, withhold next warfarin dose and give vitamin K if INR exceeds 4 because of the risk of bleeding. Assess for occult bleeding if patient receives I.V. lipid emulsion or other medical product that contains soybean oil. Such products can decrease vitamin K absorption and increase warfarin's anticoagulant effect. Patient Teaching Explain that warfarin therapy aims to prevent thrombosis by decreasing clotting ability while avoiding the risk of spontaneous bleeding. Instruct patient to take drug exactly as prescribed at the same time each evening. Urge patient to keep weekly follow-up appointments for blood tests after discharge until PT and INR levels are stabilized. Advise patient to avoid alcohol during warfarin therapy. Urge patient to take precautions against bleeding, such as using an electric shaver and a soft-bristled toothbrush. Advise him to continue these precautions for 2 to 5 days after therapy stops, as directed, because anticoagulant effect may persist during this time. Caution patient to avoid activities that could cause traumatic injury and bleeding. Advise patient to eat consistent amounts of vitamin K-rich foods, such as dark green, leafy vegetables. Urge patient to notify prescriber immediately about unusual bleeding and any unexplained symptoms, such as abnormal vaginal bleeding; dizziness; easy bruising; gum bleeding; headache; nosebleeds; prolonged bleeding from cuts; red, black, or tarry stool; red or dark brown urine; swelling; and weakness. Advise patient to consult prescriber before taking other drugs—including OTC drugs and herbal remedies—during therapy. Instruct female patient of childbearing age to stop taking warfarin and notify prescriber immediately about known or suspected pregnancy. Explain that drug may cause reversible purpletoe syndrome and that this syndrome isn't harmful. Urge patient to carry medical identification that reveals he's taking warfarin therapy.

meperidine

Demerol Class, Category, and Schedule Chemical class: Phenylpiperidine derivative opioid Therapeutic class: Analgesic Pregnancy category: C Controlled substance schedule: II Indications and Dosages To relieve moderate to severe pain Syrup, tablets, I.M. or subcutaneous injection Adults. 50 to 150 mg every 3 to 4 hr, p.r.n. Children. 1.1 to 1.8 mg/kg every 3 to 4 hr, p.r.n. To provide preoperative sedation I.V. injection Adults. 15 to 35 mg/hr, p.r.n. I.M. or subcutaneous injection Adults. 50 to 100 mg 30 to 90 min before surgery. Children. 1 to 2 mg/kg 30 to 90 min before surgery. Maximum: 100 mg every 3 to 4 hr. As adjunct to anesthesia I.V. infusion or injection Adults. Individualized. Repeated slow injections of 10 mg/ml solution or continuous infusion of dilute solution (1 mg/ml) titrated as needed. To provide obstetric analgesia I.M. or subcutaneous injection Adults. 50 to 100 mg given with regular, painful contractions; repeated every 1 to 3 hr. Route Onset Peak Duration P.O. 15 min 1 to 1.5 hr 2 to 4 hr I.V. 1 min 5 to 7 min 2 to 4 hr I.M., SubQ 10 to 15 min 30 to 50 min 2 to 4 hr Mechanism of Action Binds with opiate receptors in the spinal cord and higher levels of the CNS. In this way, meperidine stimulates mu and kappa receptors, which alters the perception of and emotional response to pain. Incompatibilities Don't mix meperidine in same syringe with aminophylline, barbiturates, heparin, iodides, methicillin, morphine sulfate, phenytoin, sodium bicarbonate, sulfadiazine, or sulfisoxazole. in Contraindications Acute asthma; hypersensitivity to meperidine, opioids, or their components; increased intracranial pressure; severe respiratory depression; upper respiratory tract obstruction; use within 14 days of MAO inhibitor therapy Interactions Drugs acyclovir, ritonavir: Possibly increased blood meperidine level alfentanil, CNS depressants, fentanyl, sufentanil: Increased risk of CNS and respiratory depression and hypotension amphetamines, MAO inhibitors: Risk of increased CNS excitation or depression with possibly fatal reactions anticholinergics: Increased risk of severe constipation antidiarrheals (such as loperamide and difenoxin and atropine): Increased risk of severe constipation and increased CNS depression antihypertensives: Increased risk of hypotension buprenorphine: Possibly decreased therapeutic effects of meperidine and increased risk of respiratory depression cimetidine: Reduced clearance and volume of distribution of meperidine hydroxyzine: Increased risk of CNS depression and hypotension metoclopramide: Possibly decreased effects of metoclopramide naloxone, naltrexone: Decreased pharmacologic effects of meperidine neuromuscular blockers: Increased risk of prolonged respiratory and CNS depression oral anticoagulants: Possibly increased anticoagulant effect and risk of bleeding phenytoin: Possibly enhanced hepatic metabolism of meperidine Activities alcohol use: Possibly increased CNS and respiratory depression and hypotension Adverse Reactions CNS: Confusion, depression, dizziness, drowsiness, euphoria, headache, increased intracranial pressure, lack of coordination, malaise, nervousness, nightmares, restlessness, seizures, syncope, tremor CV: Hypotension, orthostatic hypotension, tachycardia EENT: Blurred vision, diplopia, dry mouth GI: Abdominal cramps or pain, anorexia, constipation, ileus, nausea, vomiting GU: Dysuria, urinary frequency, urine retention RESP: Dyspnea, respiratory arrest or depression, wheezing SKIN: Diaphoresis, flushing, pruritus, rash, urticaria Other: Injection site pain, redness, and swelling; physical and psychological dependence Nursing Considerations Use meperidine with extreme caution in patients with acute abdominal conditions, hepatic or renal disorders, hypothyroidism, prostatic hyperplasia, seizures, or supraventricular tachycardia. To minimize local anesthetic effect, dilute meperidine syrup with water before administration. Give I.V. dose slowly by direct injection or as a slow continuous infusion. Mix with D5W, normal saline solution, or Ringer's or lactated Ringer's solution. Keep naloxone available when giving I.V. meperidine. Be aware that subcutaneous injection is painful and isn't recommended. Be aware that oral form of meperidine is less than half as effective as parenteral meperidine. Give I.M. form when possible, and expect to increase dosage when switching patient to oral form. Monitor patient's respiratory and cardiovascular status during treatment. Notify prescriber immediately and expect to discontinue drug if respiratory rate falls to less than 12 breaths/minute or if respiratory depth decreases. Monitor patient's bowel function to detect constipation, and assess the need for stool softeners. Assess for signs of physical dependence and abuse. Expect withdrawal symptoms to occur if drug is abruptly withdrawn after long-term use. Patient Teaching Inform patient that meperidine is a controlled substance and that he'll need identification to purchase it. Advise patient to take drug exactly as prescribed. Instruct patient to report constipation, severe nausea, and shortness or breath. Advise patient to avoid potentially hazardous activities until drug's CNS effects are known. Instruct patient to prevent postoperative atelectasis by turning, coughing, and deep-breathing. Urge patient to avoid alcohol, sedatives, and tranquilizers during therapy with meperidine.

Hydrochlorothiazide

Esidrix, Hydro-chlor, Hydro-D, Hydro-DIURIL, Microzide, Neo-Codema (CAN), Novo-Hydrazide (CAN), Oretic, Urozide (CAN) Class and Category Chemical class: Benzothiadiazide Therapeutic class: Antihypertensive, diuretic Pregnancy category: B Indications and Dosages To manage hypertension Capsules Adults. 12.5 mg daily. Oral solution, tablets Adults. 25 to 100 mg daily as a single dose or in divided doses b.i.d. Children age 6 months and over. 1 to 2 mg/kg daily as a single dose or in divided doses b.i.d. Infants under age 6 months. Up to 3 mg/kg daily. As adjunct to treat edema caused by cirrhosis, corticosteroids, estrogen, heart failure, or renal disorders Oral solution, tablets Adults. 25 to 100 mg b.i.d., once daily, or every other day for 3 to 5 days/wk. Children age 6 months and over. 1 to 2 mg/ kg daily as a single dose or in divided doses b.i.d. Infants under age 6 months. Up to 3 mg/kg daily. Route Onset Peak Duration P.O. 2 hr 4 hr 6 to 12 hr Mechanism of Action A thiazide diuretic, hydrochlorothiazide promotes the movement of sodium (Na+), chloride (Cl-), and water (H2O) from blood in the peritubular capillaries into the nephron's distal convoluted tubule, as shown at right. Initially, hydrochlorothiazide may decrease extracellular fluid volume, plasma volume, and cardiac output, which helps explain blood pressure reduction. It also may reduce blood pressure by causing direct dilation of arteries. After several weeks, extracellular fluid volume, plasma volume, and cardiac output return to normal, and peripheral vascular resistance remains decreased. Contraindications Anuria; hypersensitivity to hydrochlorothiazide, other thiazides, sulfonamide derivatives, or their components; renal failure Interactions Drugs ACTH, amphotericin B, corticosteroids: Increased electrolyte depletion, especially potassium amantadine: Possibly increased blood level and risk of toxicity of amantadine amiodarone: Increased risk of arrhythmias from hypokalemia antihypertensives: Increased antihypertensive effects barbiturates, opioids: Possibly orthostatic hypotension calcium: Possibly increased serum calcium level cholestyramine, colestipol: Reduced GI absorption of hydrochlorothiazide diazoxide: Increased antihypertensive and hyperglycemic effects of hydrochlorothiazide diflunisal: Possibly increased blood hydrochlorothiazide level digoxin: Increased risk of digitalis toxicity from hypokalemia dopamine: Possibly increased diuretic effects of both drugs insulin, oral antidiabetic drugs: Possibly increased blood glucose level lithium: Decreased lithium clearance, increased risk of lithium toxicity neuromuscular blockers: Possibly enhanced neuromuscular blockade from hypokalemia nondeplarizing skeletal muscle relaxants: Possibly increased response to muscle relaxants NSAIDs: Decreased diuretic effect of hydrochlorothiazide, increased risk of renal failure oral anticoagulants: Possibly decreased anticoagulant effects sympathomimetics: Possibly decreased antihypertensive effect of hydrochlorothiazide vitamin D: Increased risk of hypercalcemia Activities alcohol use: Possibly orthostatic hypotension Adverse Reactions CNS: Dizziness, fever, headache, insomnia, paresthesia, vertigo, weakness CV: Hypotension, orthostatic hypotension, vasculitis EENT: Blurred vision, dry mouth ENDO: Hyperglycemia GI: Abdominal cramps, anorexia, constipation, diarrhea, indigestion, jaundice, nausea, pancreatitis, vomiting GU: Decreased libido, impotence, interstitial nephritis, nocturia, polyuria, renal failure HEME: Agranulocytosis, aplastic anemia, hemolytic anemia, leukopenia, neutropenia, thrombocytopenia MS: Muscle spasms and weakness SKIN: Alopecia, cutaneous vasculitis, erythema multiforme, exfoliative dermatitis, photosensitivity, purpura, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria Other: Anaphylaxis, dehydration, hypercalcemia, hyperuricemia, hypochloremia, hypokalemia, hyponatremia, hypovolemia, metabolic alkalosis, weight loss Nursing Considerations Give hydrochlorothiazide in the morning and early in the evening to avoid nocturia. Monitor fluid intake and output, daily weight, blood pressure, and serum levels of electrolytes, especially potassium. Assess for signs of hypokalemia, such as muscle spasms and weakness. Monitor BUN and serum creatinine levels. Frequently monitor blood glucose level as ordered in diabetic patients, and expect to increase antidiabetic drug dosage, as needed. If patient has gouty arthritis, expect an increased risk of gout attacks during therapy. Patient Teaching Advise patient to take hydrochlorothiazide in the morning and early in the evening to avoid awakening during the night to urinate. Instruct patient to take drug with food or milk if adverse GI reactions occur. Tell patient to weigh herself at the same time each day wearing the same amount of clothing and to notify prescriber if she gains more than 2 lb (0.9 kg) per day or 5 lb (2.3 kg) per week. Instruct patient to eat a diet high in potassiumrich food, including citrus fruits, bananas, tomatoes, and dates. Advise patient to change position slowly to minimize effects of orthostatic hypotension. Urge patient to notify prescriber about decreased urination, muscle cramps and weakness, and unusual bleeding or bruising.

isosorbide

IMDUR, ISMO, Monoket Class and Category Chemical class: Organic nitrate Therapeutic class: Antianginal, vasodilator Pregnancy category: C Indications and Dosages To treat or prevent angina Chewable tablets Adults. 5 mg every 2 to 3 hr, p.r.n. (dinitrate). E.R. capsules Adults. 40 to 80 mg every 8 to 12 hr (dinitrate). E.R. tablets Adults. 20 to 80 mg every 8 to 12 hr (dini-trate); 30 to 60 mg daily, increased gradually as tolerated to 120 mg daily (mononitrate). S.L. tablets Adults. 2.5 to 5 mg every 2 to 3 hr, p.r.n. (dinitrate). Tablets Adults. 5 to 40 mg every 6 hr, adjusted as needed (dinitrate); 20 mg in 2 doses given 7 hr apart (mononitrate). Route Onset Peak Duration P.O.* 1 hr† Unknown 5 to 6 hr P.O. (chewable)* In 3 min Unknown 30 min to 2 hr P.O. (E.R.)* 30 min Unknown 6 to 8 hr P.O. (S.L.)* In 3 min Unknown 2 hr Mechanism of Action Isosorbide may interact with nitrate receptors in vascular smooth-muscle cell membranes. By interacting with nitrate receptors' sulfhydryl groups, the drug is reduced to nitric oxide. Nitric oxide activates the enzyme guanylate cyclase, increasing intra-cellular formation of cyclic guanosine monophosphate (cGMP). An increased cGMP level may relax vascular smooth muscle by forcing calcium out of muscle cells, causing vasodilation. This improves cardiac output by reducing primarily preload but also afterload. Contraindications Angle-closure glaucoma; cerebral hemor-rhage; concurrent use of sildenafil; head trauma; hypersensitivity to isosorbide, other nitrates, or their components; orthostatic hypotension; severe anemia Interactions Drugs acetylcholine, norepinephrine: Possibly decreased effectiveness of these drugs antihypertensives, calcium channel blockers, opioid analgesics, other vasodilators: Increased risk of orthostatic hypotension aspirin: Increased blood level and pharmacologic action of isosorbide sildenafil, tadalafil, vardenafil: Increased risk of hypotension and death sympathomimetics: Increased risk of hypotension, possibly decreased therapeutic effects of isosorbide Activities alcohol use: Increased risk of orthostatic hypotension Adverse Reactions CNS: Agitation, confusion, dizziness, headache, insomnia, restlessness, syncope, vertigo, weakness CV: Arrhythmias, orthostatic hypotension, palpitations, peripheral edema, tachycardia EENT: Blurred vision, diplopia (all drug forms); sublingual burning (S.L. form) GI: Abdominal pain, diarrhea, indigestion, nausea, vomiting GU: Dysuria, impotence, urinary frequency HEME: Hemolytic anemia MS: Arthralgia, muscle twitching RESP: Bronchitis, pneumonia, upper respiratory tract infection SKIN: Diaphoresis, flushing, rash Nursing Considerations Use isosorbide cautiously in patients with hypovolemia or mild hypotension. Monitor for increased hypotension and reduced cardiac output. Give drug 1 hour before or 2 hours after meals. Give with meals if patient experiences severe headaches or adverse GI reactions. Know that patient may experience daily headaches from isosorbide's vasodilating effects. Give acetaminophen, as prescribed, to relieve pain. WARNING Be aware that abrupt drug discontinuation may cause angina and increase the risk of MI. Monitor blood pressure frequently during isosorbide therapy, especially in the elderly; the drug may cause severe hypotension. Keep drug away from heat and light. Patient Teaching Teach patient and family to recognize signs and symptoms of angina, including chest pain, fullness, or pressure, which commonly is accompanied by sweating and nausea. Pain may radiate down the left arm or into the neck or jaw. Inform female patients and those with diabetes mellitus or hypertension that they may experience only fatigue and shortness of breath. Advise patient not to crush or chew isosor-bide E.R. capsules or tablets or S.L. tablets unless specifically ordered to do so. Instruct patient to place S.L. tablet under tongue and not to swallow it, but to let it dissolve. Explain that moisture in mouth promotes drug absorption and that tingling or burning in the mouth indicates drug effectiveness. Advise patient to chew chewable tablets well and to keep them in his mouth for 1 to 2 minutes before swallowing to enhance drug absorption. Instruct patient to take drug before any situation or activity that might precipitate angina. Advise patient to carry isosorbide with him at all times. Caution patient that abrupt drug discontinuation may cause angina and increase the risk of MI. Instruct patient to report blurred vision, fainting, increased angina attacks, rash, and severe or persistent headaches. Teach patient to reduce the effects of orthostatic hypotension by changing position slowly. Advise him to lie down if he becomes dizzy. Inform patient that drug commonly causes headache, which typically resolves after a few days of continuous therapy. Suggest that patient take acetaminophen as needed and as prescribed. Advise patient to avoid potentially hazardous activities until drug's CNS effects are known. Urge patient to avoid alcohol consumption. Instruct patient to store drug in a tightly closed container away from light and heat. Advise male patients with erectile dysfunction to alert prescriber that he is taking isosorbide because sildenafil, tadalafil, and vardenafil can cause fatal reactions when taken with isosorbide.

enalapril

Vasotec

lisinopril

Prinivil, Zestril Class and Category Chemical class: Lysine ester of enalaprilat Therapeutic class: Antihypertensive, vasodilator Pregnancy category: C (first trimester), D (later trimesters) Indications and Dosages To manage uncomplicated essential hypertension Tablets Adults. Initial: 10 mg daily. Maintenance: 20 to 40 mg daily. Maximum: 80 mg daily. Children age 6 and over with a GFR of at least 30 ml/min/1.73 m2. Initial: 0.07 mg/kg daily, adjusted according to blood pressure response up to 5 mg daily. Maximum: 0.61 mg/kg or 40 mg daily. To treat heart failure, along with digoxin and diuretics Tablets Adults. Initial: 5 mg daily. Maintenance: 5 to 20 mg daily. Maximum: 80 mg daily. To improve survival in hemodynamically stable patient after acute MI Tablets Adults. 5 mg within 24 hr after onset of symptoms, followed by 5 mg after 24 hr and 10 mg after 48 hr. Maintenance: 10 mg daily for 6 wk. Maximum: 80 mg daily. Route Onset Peak Duration P.O. 1 hr 6 to 8 hr 24 hr Mechanism of Action May reduce blood pressure by inhibiting the conversion of angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor that also stimulates the adrenal cortex to secrete aldosterone. Lisinopril may also inhibit renal and vascular production of angiotensin II. Decreased release of aldosterone reduces sodium and water reabsorption and increases their excretion, thereby reducing blood pressure. Contraindications Hypersensitivity to lisinopril, other ACE inhibitors, or their components; history of angioedema related to previous treatment with an ACE inhibitor; hereditary or idiopathic angioedema Interactions Drugs allopurinol, bone marrow depressants (such as methotrexate), procainamide, systemic corticosteroids: Increased risk of potentially fatal neutropenia or agranulocytosis cyclosporine, potassium-sparing diuretics, potassium supplements: Increased risk of hyperkalemia diuretics, other antihypertensives: Increased hypotensive effect insulin, oral antidiabetics: Increased risk of hypoglycemia lithium: Increased blood lithium level and risk of lithium toxicity NSAIDs: Possibly reduced antihypertensive effect, reduced renal function in patients with preexisting renal dysfunction sympathomimetics: Possibly reduced antihypertensive effect Foods high-potassium diet, potassium-containing salt substitutes: Increased risk of hyperkalemia Activities alcohol use: Possibly increased hypotensive effect Adverse Reactions CNS: Ataxia, confusion, dizziness, fatigue, headache, stroke, syncope, transient ischemic attack, vertigo CV: Arrhythmias, chest pain, hypotension, MI, orthostatic hypotension, palpitations, peripheral edema, vasculitis ENDO: Hyperglycemia GI: Abdominal pain, anorexia, cholestatic jaundice, diarrhea, elevated liver enzyme levels, fulminant hepatic necrosis, gastritis, hepatitis, indigestion, nausea, pancreatitis, vomiting GU: Acute renal failure, decreased libido, impotence, pyelonephritis HEME: Agranulocytosis, anemia, hemolytic anemia, neutropenia, thrombocytopenia MS: Muscle spasms, myalgia RESP: Bronchospasm, cough, dyspnea, paroxysmal nocturnal dyspnea, pulmonary embolism and infarction, upper respiratory tract infection SKIN: Alopecia, cutaneous pseudolymphoma, diaphoresis, erythema, flushing, herpes zoster, infections, pemphigus, photosensitivity, pruritus, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria Other: Anaphylaxis, angioedema Nursing Considerations Use lisinopril cautiously in patients with fluid volume deficit, heart failure, impaired renal function, or sodium depletion. To prepare pediatric suspension, add 10 ml of purified water to a polyethylene tereph-thalate (PET) bottle containing ten 20-mg tablets and shake for at least 1 minute. Add 30 ml of Bicitra diluent and 160 ml of Ora-Sweet SF to the concentrate in the PET bottle, and shake gently for several seconds. Store in refrigerator for up to 4 weeks. Shake the suspension before each use. Monitor blood pressure often, especially early in treatment. If excessive hypotension develops, expect to withhold drug for several days. WARNING If angioedema affects face, glottis, larynx, limbs, lips, mucous membranes, or tongue, notify prescriber immediately and expect to stop lisinopril and start appropriate therapy at once. If airway obstruction threatens, promptly give 0.3 to 0.5 ml of epinephrine 1:1, 000 solution subcutaneously, as prescribed. Monitor patient for anaphylaxis, especially patient being dialyzed with high-flux membranes and treated concurrently with an ACE inhibitor such as lisinopril. If anaphylaxis occurs, stop dialysis immediately and treat aggressively (antihistamines are ineffective in this situation), as ordered. Anaphylaxis has also occurred with some patients undergoing low-density lipoprotein apheresis with dextran sulfate absorption. Notify prescriber if patient has persistent, nonproductive cough, a common adverse effect of ACE inhibitors such as lisinopril. Monitor for dehydration, which can lead to hypotension. Be aware that diarrhea and vomiting can cause dehydration. Monitor patient for hepatic dysfunction because lisinopril, an ACE inhibitor, may rarely cause a syndrome that starts with cholestatic jaundice or hepatitis and progresses to fulminant hepatic necrosis. If patient develops jaundice or a marked elevation in liver enzyme levels, withhold drug and notify prescriber. If patient takes insulin or an oral antidiabetic, monitor blood glucose level closely because risk of hypoglycemia increases, especially during the first month of therapy. Patient Teaching Explain to patient that lisinopril helps to control but doesn't cure hypertension and that she may need lifelong therapy. Advise patient to take lisinopril at the same time every day. Emphasize need to take drug as ordered, even if patient feels well; caution her not to stop drug without consulting prescriber. Instruct patient to report dizziness, especially during the first few days of therapy. Inform patient that a persistent, nonproductive cough may develop during lisinopril therapy. Urge her to notify prescriber immediately if cough becomes difficult to tolerate. Advise patient to drink adequate fluid and avoid excessive sweating, which can lead to dehydration and hypotension. Make sure she understands that diarrhea and vomiting also can cause hypotension. Caution patient not to use salt substitutes that contain potassium. Instruct patient to report signs of infection, such as fever and sore throat, which may indicate neutropenia. Advise patient to change position slowly to minimize the effects of orthostatic hypotension. If patient has diabetes and takes insulin or an oral antidiabetic, urge her to monitor her blood glucose level closely and watch for symptoms of hypoglycemia. Caution female patient to notify prescriber immediately if she is or could be pregnant.

procainamide

Procan SR, Promine, Pronestyl, Pronestyl-SR Class and Category Chemical class: Ethyl benzamide monohydrochloride Therapeutic class: Antiarrhythmic Pregnancy category: C Indications and Dosages To treat life-threatening ventricular arrhythmias Capsules, tablets Adults. 50 mg/kg daily in 8 divided doses (every 3 hr), adjusted as needed and tolerated. Maximum: 6 g daily (maintenance). Children. 12.5 mg/kg q.i.d. E.R.tablets Adults. Maintenance: 50 mg/kg daily in divided doses q.i.d. (every 6 hr), adjusted as needed and tolerated. Maximum: 6 g daily (maintenance). I.V. infusion or injection Adults. Initial: 100 mg diluted in DW and given at no more than 50 mg/min. Repeated every 5 min until arrhythmia is controlled or maximum total dose of 1 g is reached. Alternatively, 10 to 15 mg/kg I.V. bolus administered at a rate of 25 to 50 mg/min. Maintenance: 1 to 4 mg/min by continuous infusion. I.M. injection Adults. 50 mg/kg daily in divided doses every 3 to 6 hr. To treat ventricular extrasystoles and arrhythmias associated with anesthesia and surgery I.V. infusion or injection Adults. Initial: 100 mg diluted in DW and administered at a rate not to exceed 50 mg/min. Dosage repeated every 5 min until arrhythmia is controlled or maximum total dose of 1 g is reached. Alternatively, 10 to 15 mg/kg I.V. bolus administered at a rate of 25 to 50 mg/min. Maintenance: 1 to 4 mg/min by continuous infusion. I.M. injection Adults. 100 to 500 mg every 3 to 6 hr. DOSAGE ADJUSTMENT For elderly patients or those with cardiac or hepatic insufficiency, dosage possibly reduced or dosing intervals increased. For patients with creatinine clearance less than 50 ml/min/1.73 m, initial dosage reduced to 1 to 2 mg/min. Route Onset Peak Duration P.O. Unknown Unknown 60 to 90 min P.O. (E.R.) Unknown 60 to 90 min Unknown I.V. Unknown Immediate Unknown I.M. 10 to 30 min 15 to 60 min Unknown Mechanism of Action Prolongs the recovery period after myocardial repolarization by inhibiting sodium influx through myocardial cell membranes. This action prolongs the refractory period, causing myocardial automaticity, excitability, and conduction velocity to decline. Contraindications Complete heart block, hypersensitivity to procainamide or its components, systemic lupus erythematosus, torsades de pointes Interactions Drugs antiarrhythmics: Additive cardiac effects anticholinergics, antidyskinetics, antihistamines: Possibly intensified atropine-like adverse effects, increased risk of ileus antihypertensives: Additive hypotensive effects antimyasthenics: Possibly antagonized effect of antimyasthenic on skeletal muscle bethanechol: Possibly antagonized cholinergic effect of bethanechol bone marrow depressants: Possibly increased leukopenic or thrombocytopenic effects bretylium: Possibly decreased inotropic effect of bretylium and enhanced hypotension neuromuscular blockers: Possibly increased or prolonged neuromuscular blockade pimozide: Possibly prolonged QT interval, leading to life-threatening arrhythmias Adverse Reactions CNS: Chills, disorientation, dizziness, light-headedness CV: Heart block (second-degree), hypotension, pericarditis, prolonged QT interval, tachycardia EENT: Bitter taste GI: Abdominal distress, anorexia, diarrhea, nausea, vomiting HEME: Agranulocytosis, neutropenia, thrombocytopenia MS: Arthralgia, myalgia RESP: Pleural effusion SKIN: Pruritus, rash Other: Drug-induced fever Nursing Considerations Place patient in a supine position before administering procainamide I.M. or I.V. to minimize hypotensive effects. Monitor blood pressure frequently and ECG tracings continuously during administration and for 30 minutes afterward. Inspect parenteral solution for particles and discoloration before giving drug; discard if particles are present or solution is darker than light amber. When possible, give drug by I.V. infusion or injection, as prescribed, rather than by I.M. injection. If drug is to be administered I.M. and patient's platelet count is below 50,000/mm3, notify prescriber immediately because patient may develop bleeding, bruising, or hematomas from procainamide-induced bone marrow suppression and thrombocytopenia. Expect to administer procainamide I.V. For I.V. injection, dilute procainamide with D5W according to manufacturer's instructions before administration. For I.V. infusion, dilute 200 to 1,000 mg of procainamide to a concentration of 2 or 4 mg/ml using 50 to 500 ml of D5W. Administer I.V. infusion with an infusion pump or other controlled-delivery device. Don't exceed 500 mg in 30 minutes by I.V. infusion or 50 mg/min by I.V. injection because heart block or cardiac arrest may occur. Anticipate that patient has reached maximum clinical response when ventricular tachycardia resolves, hypotension develops, or QRS complex is 50% wider than original width. Expect to administer first oral dose 3 to 4 hours after last I.V. dose. Instruct patient to swallow E.R. procainamide tablets whole, without breaking, crushing, or chewing them. If patient has trouble swallowing, advise her to crush regular-release tablets or open capsules and mix contents with food or fluid. Instruct patient to take drug 1 hour before or 2 hours after meals with a full glass of water. Inform her that she may take procainamide with food if GI irritation develops. Urge patient to obtain needed dental work before therapy starts or after blood count returns to normal because drug can cause myelosuppression and increased risk of bleeding and infection. Encourage good oral hygiene during therapy, and urge patient to consult prescriber before having dental procedures. Advise patient to notify prescriber immediately about bruising, chills, diarrhea, fever, or rash.

benzatropine

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hydrocodone

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librium

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allopurinol

Apo-Allopurinol (CAN), Lopurin, Purinol (CAN), Zyloprim, Aloprim Class and Category Chemical class: Hypoxanthine derivative, xanthine oxidase inhibitor Therapeutic class: Antigout Pregnancy category: C Indications and Dosages To treat gout and hyperuricemia TABLETS Adults. 200 to 600 mg daily in divided doses, depending on disease severity. Usual: 200 to 300 mg daily. Maximum: 800 mg daily. To treat secondary hyperuricemia caused by neoplastic disease TABLETS Children ages 6 to 10. 300 mg daily, adjusted after 48 hr, depending on response to treatment. Children under age 6. 150 mg daily, adjusted after 48 hr, depending on response to treatment. To prevent gout attack TABLETS Adults. 100 mg daily increased by 100 mg/wk until serum uric acid level is 6 mg/dl or less. To prevent uric acid nephropathy during vigorous treatment of neoplastic disease TABLETS Adults. 600 to 800 mg daily for 2 to 3 days, then adjusted to keep serum uric acid level within normal limits. To treat recurrent calcium oxalate calculi TABLETS Adults. 200 to 300 mg daily as a single dose or in divided doses, adjusted based on 24-hr urine urate level. To treat increased serum and urine uric acid levels in patients with leukemia, lymphoma, and solid tumors whose cancer chemotherapy has increased those levels and who can't tolerate oral therapy I.V. INFUSION Adults. 200 to 400 mg/m2 daily as a single infusion or in equally divided infusions every 6, 8, or 12 hr. Maximum: 600 mg daily. Children. 200 mg/m2 daily as a single infusion or in equally divided infusions every 6, 8, or 12 hr. Route Onset Peak Duration P.O. 2-3 days 1-3 wk* 1-2 wk Mechanism of Action Inhibits uric acid production by inhibiting xanthine oxidase, the enzyme that converts hypoxanthine and xanthine to uric acid. Allopurinol is metabolized to oxipurinol, which also inhibits xanthine oxidase. Incompatibilities Don't combine I.V. allopurinol in solution with amikacin, amphotericin B, carmustine, cefotaxime sodium, chlorpromazine hydrochloride, cimetidine hydrochloride, clindamycin phosphate, cytarabine, dacarbazine, daunorubicin hydrochloride, diphenhydramine hydrochloride, doxorubicin hydrochloride, doxycycline hyclate, droperidol, floxuridine, gentamicin sulfate, haloperidol lactate, hydroxyzine hydrochloride, idarubicin hydrochloride, imipenem-cilastatin sodium, mechlorethamine hydrochloride, meperidine hydrochloride, metoclopramide hydrochloride, methylprednisolone sodium succinate, minocycline hydrochloride, nalbuphine hydrochloride, netilmicin sulfate, ondansetron hydrochloride, prochlorperazine edisylate, promethazine hydrochloride, sodium bicarbonate, streptozocin, tobramycin sulfate, vinorelbine tartrate. Contraindications Hypersensitivity to allopurinol Interaction DRUGS ACE inhibitors: Increased risk of hypersensitivity reactions amoxicillin, ampicillin: Increased risk of rash azathioprine, mercaptopurine: Inactivation of these drugs chlorpropamide: Increased risk of hypoglycemia in patients with renal insufficiency cyclophosphamide, other cytotoxic drugs: Enhanced bone marrow suppression dicumarol: Increased half-life and anticoagulant action of dicumarol thiazide diuretics: Possibly increased risk of allopurinol toxicity uricosuric agents: Increased urinary excretion of uric acid vitamin C (large doses): Possibly urine acidification and increased risk of renal calculus formation Adverse Reactions CNS: Chills, drowsiness, fever, headache, neuritis, paresthesia, peripheral neuropathy, somnolence CV: Vasculitis EENT: Epistaxis, loss of taste GI: Abdominal pain, diarrhea, dysphagia, elevated liver function test results, gastritis, granulomatous hepatitis, hepatic necrosis, hepatomegaly, nausea, vomiting GU: Exacerbated renal calculi, renal failure HEME: Agranulocytosis, aplastic anemia, bone marrow depression, eosinophilia, leukocytosis, leukopenia, thrombocytopenia MS: Arthralgia, exacerbation of gout, myopathy SKIN: Alopecia; ecchymosis; jaundice; maculopapular, scaly, or exfoliative rash (sometimes fatal); pruritus; urticaria Nursing Considerations As ordered, obtain baseline CBC and uric acid level, and review results of renal and liver function tests before and during allopurinol therapy. Reconstitute and dilute I.V. preparation to a concentration of 6 mg/ml or less. To decrease risk of calculus formation, maintain fluid intake of up to 3 L daily and monitor patient for output of 2 L daily. Also, don't give vitamin C. PATIENT TEACHING Advise patient to take allopurinol after meals and to drink at least 10 large glasses of water daily. Instruct patient to report unusual bleeding or bruising, fever, chills, gout attack, numbness, and tingling. Inform patient that acute gout attacks may occur more often early in allopurinol treatment and that results may not be noticeable for 2 weeks or longer. Instruct patient not to drive or perform hazardous tasks if drug causes drowsiness.

alprazolam

Apo-Alpraz (CAN), Niravam, Novo-Alprazol (CAN), Nu-Alpraz, Xanax, Xanax XR Class and Category Class, Category, and Schedule Benzodiazepine Chemical class: Benzodiazepine Therapeutic class: Antianxiety drug Pregnancy category: D Controlled substance schedule: IV Indications and Dosages To control anxiety disorders, relieve anxiety (short-term therapy), or treat anxiety associated with depression ORALLY DISINTEGRATING TABLETS, TABLETS Adults. Initial: 0.25 to 0.5 mg t.i.d., adjusted to patient's needs. Maximum: 4 mg daily in divided doses. To treat panic attack ORALLY DISINTEGRATING TABLETS, TABLETS Adults. Initial: 0.5 mg t.i.d., increased every 3 to 4 days by no more than 1 mg daily, based on patient response. Maximum: 10 mg daily in divided doses. E.R. TABLETS Adults. Initial: 0.5 to 1 mg daily in morning, increased every 3 to 4 days by no more than 1 mg daily, based on patient response. Maximum: 10 mg daily as single dose in morning. Mechanism of Action May increase effects of gamma-aminobutyric acid (GABA) and other inhibitory neurotransmitters by binding to specific benzodiazepine receptors in limbic and cortical areas of the CNS. GABA inhibits excitatory stimulation, which helps control emotional behavior. The limbic system contains many benzodiazepine receptors, which may help explain drug's antianxiety effects. Contraindications Acute angle-closure glaucoma; hypersensitivity to alprazolam, its components, or other benzodiazepines; itraconazole or ketoconazole therapy Interaction DRUGS antacids: Altered alprazolam absorption rate cimetidine, disulfiram, fluoxetine, isoniazid, metoprolol, oral contraceptives, propoxyphene, propranolol, valproic acid: Decreased alprazolam elimination and increased effects CNS depressants: Possibly increased CNS effects of both drugs digoxin: Possibly increased serum digoxin level, causing digitalis toxicity itraconazole, ketoconazole: Possibly profoundly inhibited alprazolam metabolism levodopa: Decreased effects of levodopa neuromuscular blockers: Possibly potentiated or antagonized effects of these drugs phenytoin: Possibly increased serum phenytoin level, causing phenytoin toxicity probenecid: Possibly faster onset or prolonged effects of alprazolam ranitidine: Possibly reduced absorption of alprazolam alcohol use: Enhanced adverse CNS effects of alprazolam Adverse Reactions CNS: Agitation, akathisia, confusion, depression, dizziness, drowsiness, fatigue, hallucinations, headache, insomnia, irritability, lack of coordination, light-headedness, memory loss, nervousness, paresthesia, rigidity, speech problems, syncope, tremor, weakness CV: Chest pain, edema, hypotension, nonspecific ECG changes, palpitations, peripheral edema, tachycardia EENT: Blurred vision, altered salivation, dry mouth, nasal congestion, tinnitus ENDO: Galactorrhea, gynecomastia, hyperprolactinemia GI: Abdominal discomfort, anorexia, constipation, diarrhea, elevated liver function test results, hepatitis, hepatic failure, nausea, vomiting GU: Altered libido, urinary hesitancy MS: Dysarthria, muscle rigidity and spasms RESP: Hyperventilation, upper respiratory tract infection SKIN: Dermatitis, diaphoresis, pruritus, rash, Stevens-Johnson syndrome Other: Angioedema, weight gain or loss Nursing Considerations Expect to give a higher dosage if patient's panic attacks occur unexpectedly or during such activities as driving. Because use can lead to dependency, expect to reduce dosage gradually when stopping drug. To prevent withdrawal symptoms, don't stop drug abruptly. PATIENT TEACHING Warn against stopping drug abruptly because withdrawal symptoms may occur. Instruct patient never to increase prescribed dose because of risk of dependency. Tell patient prescribed orally disintegrating tablets to use dry hands to remove tablet from bottle just prior to administration. Then she should immediately place the tablet on top of her tongue to dissolve. Inform patient that drinking a liquid beverage is not necessary after taking this form of alprazolam. Urge patient to avoid drinking alcohol during alprazolam therapy. Advise patient to avoid driving and activities that require alertness until alprazolam's effects are known. Instruct female patient of childbearing age to notify prescriber immediately if she becomes or might be pregnant. Drug isn't recommended during pregnancy.

baclofen

Apo-Baclofen (CAN), Lioresal, Lioresal Intrathecal, Novo-Baclofen (CAN) Class and Category Chemical class: Gamma-aminobutyric acid (GABA) chlorophenyl derivative Therapeutic class: Skeletal muscle relaxant, spasmolytic Pregnancy category: C Indications and Dosages To relieve symptoms of spasticity caused by multiple sclerosis (particularly flexor spasms and pain, clonus, and muscle rigidity) and spasticity from spinal cord injury or disease and brain injury Tablets Adults and children age 12 and over. 5 mg t.i.d. for 3 days, then 10 mg t.i.d. for 3 days, then 15 mg t.i.d. for 3 days, then 20 mg t.i.d. for 3 days, then increased if needed up to 80 mg daily. Usual dosage ranges from 40 to 80 mg daily. To relieve severe symptoms of spasticity of spinal cord origin when symptoms don't respond to oral drug or when oral drug causes severe adverse CNS effects Intrathecal bolus, intrathecal infusion Adults. For screening before implantable pump insertion: 50 mcg in 1 ml of sterile preservative-free sodium chloride for injection as bolus injection into intrathecal space over 1 min or more. After 4 to 8 hr, if symptoms don't improve as much as desired, second bolus of 75 mcg in 1.5 ml of sterile preservative-free sodium chloride for injection injected after 24 hr followed by third bolus of 100-mcg/2 ml dilution injected after another 24 hr, if needed. After implantable pump insertion: Effective screening dose doubled and infused over 24 hr. Or effective screening dose (if it provided desired effects for more than 12 hr) infused over 24 hr. For spasticity of spinal cord origin after implantable pump insertion: After first 24 hr, daily dose increased by 10% to 30% once every 24 hr until desired effects achieved. For spasticity of cerebral origin after implantable pump insertion: Daily dose increased by 5% to 15% once every 24 hr until desired effects achieved. For long-term maintenance therapy in spasticity of spinal cord origin: 12 to 2,003 mcg/ day (usual dose 300 to 800 mcg daily). Lowest possible therapeutic dose should be used. If adverse effects occur, daily dose may be decreased by 10% to 20%. During periodic pump refills, daily dose may be increased by 10% up to 40% to control symptoms adequately. For long-term maintenance therapy in spasticity of cerebral origin: 90 to 703 mcg daily (usual) but ranging from 22 to 1,400 mcg/ day. If adverse effects occur, daily dose may be decreased by 10% to 20%. During periodic pump refills, daily dose may be increased by 5% to 20% to control symptoms adequately. Children. For screening before implantable pump insertion: 1 ml of a 50-mcg/ml dilution or 1 ml of a 25-mcg/ml dilution (if child is very young) as bolus injection into intrathecal space over 1 min or more. After 4 to 8 hr, if symptoms don't improve as desired, second bolus of 75 mcg in 1.5 ml of sterile preservative-free sodium chloride for injection injected after 24 hr followed by third bolus of 100-mcg/2 ml dilution injected after another 24 hr, if needed. After implantable pump insertion: Daily dose increased by 5% to 15% once every 24 hr until the desired effect is achieved. For maintenance therapy: In children over age 12: 90 to 703 mcg daily (usual) but ranging from 22 to 1,400 mcg daily. In children under age 12: 274 mcg daily (average) but ranging from 24 to 1,199 mcg daily. Route Onset Peak Duration P.O. Hours to weeks Unknown Unknown Intrathecal bolus injection 30 to 60 min About 4 hr 4 to 8 hr Intrathecal infusion 6 to 8 hr 24 to 48 hr Unknown Mechanism of Action May inhibit transmission of monosynaptic and polysynaptic impulses, similar to effects of gamma-aminobutyric acid (GABA). Baclofen may work in the spinal cord at the afferent spinal end of upper motor neurons, where it hyperpolarizes nerve fibers and inhibits impulse transmission. This reduces excess muscle activity caused by muscle hypertonia, spasms, and spasticity. Contraindications Hypersensitivity to baclofen; treatment of skeletal muscle spasm resulting from rheumatic disorders, cerebral palsy, Parkinson's disease, or stroke (oral form only) Interactions Drugs CNS depressants: Possibly increased CNS depression epidural morphine: Possibly hypotension and dyspnea Activities alcohol use: Possibly increased CNS depression Adverse Reactions CNS: Abnormal gait, anxiety, ataxia, chills, coma, confusion, depression, dizziness, drowsiness, dystonia, emotional lability, euphoria, excitement, fatigue, fever, hallucinations, headache, hypertonia, hypothermia, hypotonia, impaired concentration, insomnia, lack of coordination, lethargy, memory loss, paresthesia, personality disorder, seizures, somnolence, stroke, syncope, tremor, weakness CV: Bradycardia, chest pain, chest tightness, deep vein thrombosis, hypertension, orthostatic hypotension, palpitations, peripheral edema EENT: Amblyopia, blurred vision, diplopia, dry mouth, miosis, mydriasis, nasal congestion, nystagmus, photophobia, ptosis, rhinitis, slurred speech, strabismus, taste loss, tinnitus ENDO: Hyperglycemia GI: Abdominal pain, anorexia, constipation, dysphagia, elevated liver function test results, flatulence, ileus, indigestion, nausea, vomiting GU: Albuminuria, bladder spasms, dysuria, enuresis, hematuria, impotence, renal failure, sexual dysfunction, urinary frequency, urinary incontinence, urine retention HEME: Anemia MS: Muscle twitching RESP: Aspiration pneumonia, pulmonary embolism, respiratory depression SKIN: Alopecia, diaphoresis, facial edema, flushing, pruritus, rash, urticaria, wound dehiscence Other: Dehydration, infection at pump implantation site, weight loss Nursing Considerations Expect to start baclofen therapy at a low dose and gradually increase it until desired effects are achieved. WARNING Before screening dose is administered, expect prescriber to ensure that patient is free of infection to prevent systemic infection from interfering with patient's response. Before implantable pump insertion, also expect prescriber to ensure that patient is free of infection to reduce risk of complications and interference with determining most appropriate dose. Use baclofen cautiously in patients who have a history of autonomic dysreflexia. No-ciceptor stimulation may precipitate autonomic dysreflexia. Be aware that abrupt withdrawal of intrathecal infusion may produce symptoms similar to autonomic dysreflexia, high fever, life-threatening complications such as multiple organ-system failure, and death. WARNING Never give the intrathecal form of baclofen by I.V., I.M., or subcutaneous routes. Assess patient for signs of effectiveness, such as relief of spasms, pain, and muscle rigidity. Because CNS depression can occur, take safety precautions to help prevent injury. Also take precautions for patients who use spasticity to maintain locomotion or upright posture and balance. Relief of spasticity may increase risk of falls and injury. WARNING Because continuous intrathecal infusion increases risk of life-threatening CNS depression, keep emergency equipment nearby. Expect baclofen to be discontinued slowly; hallucinations and seizures may occur with abrupt withdrawal Patient Teaching Teach patient how to care for and operate programmable implanted pump. Have her demonstrate all procedures. Advise patient not to stop taking baclofen abruptly. Stress the importance of keeping follow-up appointments for intrathecal infusion. Instruct patient to avoid driving and other activities that require mental alertness, coordination, or physical dexterity until baclofen's effects are known. Urge patient to contact prescriber before taking OTC drugs, such as cough syrups and cold remedies, which may increase risk of sedation. Advise patient to notify prescriber if spasticity increases or baclofen is no longer effective.

Carbamazepine

Apo-Carbamazepine (CAN), Atretol, Carbatrol, Epitol, Equetro, Novo-Carbamaz (CAN), Tegretol, Tegretol-XR Class and Category Chemical class: Tricyclic iminostilbene derivative Therapeutic class: Analgesic, anticonvulsant Pregnancy category: C Indications and Dosages To treat epilepsy E.R. capsules (Carbatrol), E.R. tablets (Tegretol-XR) Adults and children age 12 and over. Initial: 200 mg b.i.d. Increased weekly by 200 mg daily, if needed. Maximum: 1,600 mg daily in adults, 1,200 mg daily in children age 16 and over, and 1,000 mg daily in children ages 12 to 16. Children ages 6 to 12. Initial: 100 mg b.i.d. Increased weekly by 100 mg daily, if needed. Maximum: 1,000 mg daily. Oral suspension Adults and children age 12 and over. Initial: 100 mg q.i.d. Increased weekly by 200 mg daily, if needed, given in divided doses t.i.d or q.i.d. Maximum: 1,600 mg daily in adults, 1,200 mg daily in children age 16 and over, and 1,000 mg daily in children ages 12 to 16. Children ages 6 to 12. Initial: 50 mg q.i.d. Increased weekly by 100 mg daily, if needed, given in divided doses t.i.d or q.i.d. Maximum: 1,000 mg daily. Children up to age 6. Initial: 10 to 20 mg/kg/ day in divided doses q.i.d. Maximum: 35 mg/kg daily. Tablets Adults and children age 12 and over. Initial: 200 mg b.i.d. Increased weekly by 200 mg/ day, if needed, given in divided doses t.i.d. or q.i.d. Maximum: 1,600 mg daily in adults, 1,200 mg daily in children age 16 and over, and 1,000 mg daily in children ages 12 to 16. Children ages 6 to 12. Initial: 100 mg b.i.d. Increased weekly by 100 mg daily, if needed, given in divided doses t.i.d. or q.i.d. Maximum: 1,000 mg daily. Children up to age 6. Initial: 10 to 20 mg/ kg daily in divided doses b.i.d. or t.i.d. Increased weekly, if needed, divided and given t.i.d. or q.i.d. Maximum: 35/kg daily. To relieve pain in trigeminal neuralgia E.R. capsules (Carbatrol), E.R. tablets (Tegretol-XR), tablets Adults. Initial: 100 mg b.i.d. Increased by up to 200 mg daily, if needed, in increments of 100 mg every 12 hr. Maintenance: 400 to 800 mg/day. Maximum: 1,200 mg daily. Oral suspension (100 mg/5 ml) Adults. 50 mg q.i.d. Increased by up to 200 mg daily, if needed, in increments of 50 mg q.i.d. Maintenance: 400 to 800 mg daily. Maximum: 1,200 mg daily. To treat acute manic and mixed episodes in bipolar disorder E.R. capsules (Equetro) Adults. Initial: 200 mg b.i.d., increased as needed in 200-mg increments. Maximum: 1,600 mg daily. Route Onset Peak Duration P.O. (all forms) In 1 mo* Unknown Unknown Mechanism of Action Normally, sodium moves into a neuronal cell by passing through a gated sodium channel in the cell membrane. Carbamazepine may prevent or halt seizures by closing or blocking sodium channels, as shown, thus preventing sodium from entering the cell. Keeping sodium out of the cell may slow nerve impulse transmission, thus slowing the rate at which neurons fire. Contraindications History of bone marrow depression; hypersensitivity to carbamazepine, tricyclic compounds, or their components; MAO inhibitor or nefazodone therapy Interactions Drugs acetaminophen (long-term use): Increased metabolism, leading to acetaminophen-induced hepatotoxicity or decreased acetaminophen effectiveness acetazolamide, cimetidine, clarithromycin, danazol, diltiazem, erythromycin, fluconazole, fluoxetine, fluvoxamine, isoniazid, itraconazole, ketoconazole, loratadine, niacinamide, nicotinamide, propoxyphene, protease inhibitors, terfenadine, troleandomycin, valproate, verapamil: Increased blood carbamazepine level alprazolam, amitriptyline, bupropion, buspirone, citalopram, clobazam, clonazepam, clozapine, cyclosporine, delavirdine, desipramine, diazepam, dicumarol, doxycycline, ethosuximide, felodipine, glucocorticoids, haloperidol, itraconazole, lamotrigine, levothyroxine, lorazepam, methadone, methsuximide, midazolam, mirtazapine, nortriptyline, olanzapine, oral contraceptives, oxcarbazepine, phenytoin, praziquantel, protease inhibitors, quetiapine, risperidone, theophylline, tiagabine, topiramate, tramadol, triazolam, trazodone, valproate, warfarin, ziprasidone, zonisamide: Decreased blood levels of these drugs cisplatin, doxorubicin, felbamate, methsuximide, phenytoin, rifampin, theophylline: Decreased blood carbamazepine level clomipramine, phenytoin, primidone: Increased blood levels of these drugs felbamate: Decreased blood level of felbamate or carbamazepine isoniazid: Increased risk of carbamazepine toxicity and isoniazid hepatotoxicity lamotrigine, phenobarbital, primidone, tricyclic antidepressants, valproic acid: Decreased blood levels of these drugs, increased blood level of carbamazepine lithium: Increased risk of CNS toxicity nefazodone: Decreased nefazodone effectiveness and increased blood carbamazepine level nondepolarizing neuromuscular blockers: Possibly reduced duration or decreased effectiveness of neuromuscular blocker oral anticoagulants: Increased metabolism and decreased effectiveness of anticoagulant Foods grapefruit juice: Increased blood carbamazepine level Activities alcohol use: Increased sedative effect Adverse Reactions CNS: Chills, confusion, dizziness, drowsiness, fatigue, fever, headache, syncope, talkativeness, unsteadiness, visual hallucinations CV: Arrhythmias, including AV block; edema; heart failure; hypertension; hypotension; thromboembolism; thrombophlebitis; worsened coronary artery disease EENT: Blurred vision, conjunctivitis, dry mouth, glossitis, nystagmus, oculomotor disturbances, stomatitis, tinnitus, transient diplopia ENDO: Syndrome of inappropriate ADH secretion, water intoxication GI: Abdominal pain, anorexia, constipation, diarrhea, dyspepsia, elevated liver function test results, hepatitis, nausea, pancreatitis, vomiting GU: Acute urine retention, albuminuria, azotemia, glycosuria, impotence, oliguria, renal failure, urinary frequency HEME: Acute intermittent porphyria, agranulocytosis, aplastic anemia, bone marrow depression, eosinophilia, leukocytosis, leukopenia, pancytopenia, thrombocytopenia MS: Arthralgia, leg cramps, myalgia RESP: Pulmonary hypersensitivity (dyspnea, fever, pneumonia, or pneumonitis) SKIN: Aggravation of disseminated lupus erythematosus, alopecia, altered skin pigmentation, diaphoresis, erythema multiforme, erythema nodosum, exfoliative dermatitis, jaundice, Lyell's syndrome, photosensitivity reactions, pruritic and erythematous rash, purpura, Stevens-Johnson syndrome, urticaria Other: Adenopathy, lymphadenopathy Nursing Considerations Avoid using carbamazepine in patients with a history of hepatic porphyria because it may prompt an acute attack. WARNING If patient has Asian ancestry, make sure he has been evaluated for the genetic allelic variant HLA-B 1502 before starting carbamazepine therapy. Patients positive for HLA-B 1502 shouldn't take carbamazepine because the risk of serious, sometimes fatal, dermatologic reactions is ten times higher than in patients without this variant. Use carbamazepine cautiously in patients with impaired hepatic function because it's mainly metabolized in the liver. Monitor results of liver function tests, as directed. Monitor patient closely for adverse reactions because many are serious. Periodically monitor blood carbamazepine level to assess for therapeutic and toxic levels; a blood level of 6 to 12 mcg/ml is optimal for anticonvulsant effects. WARNING Monitor WBC and platelet counts monthly for first 2 months. Decreased counts may indicate bone marrow depression. Withdraw carbamazepine therapy gradually to minimize the risk of seizures. Patient Teaching Tell patient to take carbamazepine with food (except the oral suspension form, which shouldn't be taken with other liquid drugs or diluents). Warn patient about possible dizziness, blurred vision, and unsteadiness. Inform patient that the coating of E.R. tablets isn't absorbed and may appear in stool. Advise patient not to crush or chew E.R. capsules or tablets. If he can't swallow capsules whole, have him open them and sprinkle contents on food. Urge patient to wear sunscreen and protective clothing to prevent photosensitivity. Tell patient to report unusual bleeding or bruising, fever, rash, or mouth ulcers. Warn female patients that drug decreases oral contraceptive effectiveness, and urge her to use another form of contraception. Because drug may cause fetal harm, urge her to notify prescriber if pregnancy is suspected or occurs.

diazepam

Apo-Diazepam (CAN), Diastat, Diazepam Intensol, Dizac, Novo-Dipam (CAN), Valium, Vivol (CAN) Class, Category, and Schedule Chemical class: Benzodiazepine Therapeutic class: Anticonvulsant, anxi-olytic, sedative-hypnotic, skeletal muscle relaxant Pregnancy category: D Controlled substance schedule: IV Indications and Dosages To relieve anxiety Oral Solution, Tablets Adults. 2 to 10 mg b.i.d. to q.i.d. Children age 6 months and over. Initial: 1 to 2.5 mg t.i.d. or q.i.d. Increased gradually as needed and tolerated. I.V. or I.M. Injection Adults. 2 to 5 mg every 3 to 4 hr, p.r.n., for moderate anxiety; 5 to 10 mg every 3 to 4 hr, p.r.n., for severe anxiety. Children. Individualized dosage. Maximum: 0.25 mg/kg given over 3 min and repeated after 15 to 30 min if needed and after another 15 to 30 min if needed. To treat symptoms of acute alcohol withdrawal Oral Solution, Tablets Adults. 10 mg t.i.d. or q.i.d. during first 24 hr. Then 5 mg t.i.d. or q.i.d., if needed. I.V. or I.M. Injection Adults. 10 mg and then 5 to 10 mg in 3 to 4 hr, if needed. To provide muscle relaxation, to provide sedation Oral Solution, Tablets Adults. 2 to 10 mg t.i.d. or q.i.d. Children age 6 months and over. Initial: 1 to 2.5 mg t.i.d. or q.i.d. Increased gradually as needed and tolerated. I.V. or I.M. Injection Adults. 2 to 5 mg every 3 to 4 hr, p.r.n., for moderate anxiety; 5 to 10 mg every 3 to 4 hr, p.r.n., for severe anxiety. Children. Individualized dosage. Maximum: 0.25 mg/kg given over 3 min and repeated after 15 to 30 min if needed and after another 15 to 30 min if needed. To treat seizures Oral Solution, Tablets Adults. 2 to 10 mg b.i.d. to q.i.d. Children age 6 months and over. Initial: 1 to 2.5 mg t.i.d. or q.i.d. Increased gradually as needed and tolerated. To treat status epilepticus and severe recurrent seizures I.V. Injection Adults. 5 to 10 mg repeated every 10 to 15 min, as needed, up to a cumulative dose of 30 mg. Regimen repeated, if needed, in 2 to 4 hr. (Use I.M. route if I.V. access is impossible.) Children age 5 and over. 1 mg repeated every 2 to 5 min, as needed, up to a cumulative dose of 10 mg. Regimen repeated, if needed, in 2 to 4 hr. Children ages 1 month to 5 years. 0.2 to 0.5 mg repeated every 2 to 5 min, as needed, up to a cumulative dose of 5 mg. Regimen repeated, if needed, in 2 to 4 hr. Rectal Gel Adults and adolescents. 0.2 mg/kg rounded up to next available unit dose (or rounded down for elderly or debilitated patient). Repeated in 4 to 12 hr, if needed. Children ages 6 to 12. 0.3 mg/kg rounded up to next available unit dose. Repeated in 4 to 12 hr, if needed. Children ages 2 to 6. 0.5 mg/kg rounded up to next available unit dose. Repeated in 4 to 12 hr, if needed. To provide preoperative sedation I.V. or I.M. Injection Adults. 5 to 10 mg 30 min before surgery. To reduce anxiety before cardioversion I.V. Injection Adults. 5 to 15 mg 5 to 10 min before procedure. To reduce anxiety before endoscopic procedures I.V. Injection Adults. Up to 20 mg titrated to desired sedation and administered immediately before procedure. I.M. Injection Adults. 5 to 10 mg 30 min before procedure. To treat tetanus I.V. or I.M. Injection Adults and children age 5 and over. Initial: 5 to 10 mg repeated every 3 to 4 hr, if needed. Sometimes larger doses are needed for adults. Children ages 1 month to 5 years. 1 to 2 mg repeated every 3 to 4 hr, as needed. Mechanism of Action May potentiate the effects of gamma-aminobutyric acid (GABA) and other inhibitory neurotransmitters by binding to specific benzodiazepine receptors in the limbic and cortical areas of the CNS. GABA inhibits excitatory stimulation, which helps control emotional behavior. The limbic system contains a highly dense area of benzodiazepine receptors, which may explain the drug's antianxiety effects. Diazepam suppresses the spread of seizure activity caused by seizure-producing foci in the cortex, thalamus, and limbic structures. Incompatibilities Don't mix diazepam injection with aqueous solutions. Don't mix diazepam emulsion for I.M. injection with morphine or glycopyrrolate or administer it through an infusion set that contains polyvinyl chloride. in Contraindications Acute angle-closure glaucoma, hypersensitivity to diazepam or its components, untreated open-angle glaucoma Interactions Drugs antacids: Altered rate of diazepam absorption anticonvulsants: Decreased effectiveness of these drugs cimetidine, disulfiram, fluoxetine, fluvoxamine, isoniazid, itraconazole, ketoconazole, metoprolol, omeprazole, oral contraceptives, propoxyphene, propranolol, valproic acid: Decreased diazepam metabolism, increased blood level and risk of adverse effects of diazepam CNS depressants: Increased CNS depressant effects digoxin: Increased serum digoxin level and risk of digitalis toxicity levodopa: Decreased antidyskinetic effect of levodopa phenytoin: Decreased metabolic elimination of phenytoin, increased risk of adverse reactions probenecid: Faster onset or more prolonged effects of diazepam ranitidine: Delayed elimination and increased blood level of diazepam rifampin: Decreased blood diazepam level theophyllines: Antagonized sedative effect of diazepam Activities alcohol use: Increased CNS depression Adverse Reactions CNS: Anterograde amnesia, anxiety, ataxia, confusion, depression, dizziness, drowsiness, fatigue, headache, insomnia, lethargy, light-headedness, paradoxical reactions, psychiatric effects, sedation, sleepiness, slurred speech, suicidal ideation, tremor, vertigo CV: Hypotension, palpitations, tachycardia EENT : Blurred vision, diplopia, dry mouth, increased salivation GI: Anorexia, constipation, diarrhea, elevated liver enzymes, jaundice, nausea, vomiting GU: Libido changes, urinary incontinence, urine retention HEME: Neutropenia MS: Dysartrhia, muscle weakness RESP: Respiratory depression SKIN: Dermatitis Other: Physical and psychological dependence Nursing Considerations Use diazepam with extreme caution in patients with a history of alcohol or drug abuse, because drug can cause physical and psychological dependence, and in patients with hepatic disorders such as hepatic fibrosis and hepatitis because of potentially significant increase in drug's half-life. Use diazepam cautiously in patients with hepatic or renal impairment. Severe hepatic impairment is a contraindication to use. Expect to give a lower dose of diazepam in a patient with chronic respiratory insufficiency because of the risk of respiratory depression. Mix concentrated oral solution (Intensol) with liquid or semisolid food. Use supplied calibrated dropper for accurate dosing. Protect diazepam injection from light. Don't use solution that's more than slightly yellow or that contains precipitate. Give I.M. injection into deltoid muscle for rapid and complete absorption. Using other sites may cause slow, erratic absorption. Before administering emulsion form, ask if patient is allergic to soybeans because this form contains soybean oil. For an infant or a child, administer I.V. injection slowly over 3 minutes in a dose not to exceed 0.25 mg/kg. Give emulsion form within 6 hours of opening ampule because it contains no preservatives and allows rapid microbial growth. Use polyethylene-lined or glass infusion sets and polyethylene or polypropylene plastic syringes for administration. Don't use a filter with a pore size less than 5 microns because a smaller size may break down the emulsion. Don't mix emulsion form with anything other than its emulsion base. Otherwise, it may become unstable and increase the risk of serious adverse reactions. Monitor patient for adverse reactions, especially if she has hypoalbuminemia, which increases the risk of sedation. WARNING Watch for signs of physical and psychological dependence: a strong desire or need to continue taking diazepam, a need to increase the dose to maintain drug effects, and posttherapy withdrawal symptoms, such as abdominal cramps, insomnia, irritability, nervousness, and tremor. Monitor patient closely for increase in frequency or severity of grand mal seizures when diazepam is used with standard anticonvulsant therapy. Dosage of other anticonvulsants may need to be increased. Avoid abrupt withdrawal of diazepam, as ordered, when used as part of the patient's seizure control regimen because a transient increase in frequency or severity of seizures may occur. Monitor severely depressed patient or patient with depression-related anxiety for suicidal tendencies, particularly when therapy starts and dosage changes, because depression may worsen temporarily during these times. Watch for psychiatric and paradoxical reactions to diazepam, especially in children and the elderly. If reations occur, notify prescriber and expect drug to be discontinued. Monitor patient for decreased drug effectiveness, which can occur with prolonged use. Check patient's blood counts and liver function periodically, as ordered, because prolonged diazepam therapy rarely causes neutropenia and jaundice. Patient Teaching Instruct patient not to take more drug than prescribed, more often, or for a longer time. Warn her that physical and psychological dependence can occur, and teach her to recognize signs of dependence. Advise patient not to take drug to relieve everyday stress. Advise patient to avoid hazardous activities until drug's CNS effects are known. Advise patient to avoid CNS depressants and alcohol during therapy. Instruct patient not to stop taking drug abruptly without prescriber's supervision. If patient has a history of seizures, warn that abrupt drug withdrawal may trigger them. Instruct patient to mix Diazepam Intensol with water, soda, or a similar beverage; applesauce; or pudding just before taking it. Caution her not to save the mixture for later. Also tell patient to use calibrated dropper that's provided to measure each dose. Teach patient how to self-administer a rectal form, if prescribed. Instruct female patient of childbearing age to notify prescriber immediately if she is or could be pregnant because diazepam therapy will need to be discontinued. Urge family or caregiver to watch patient closely for suicidal tendencies, especially when therapy starts or dosage changes.

Furosemide

Apo-Furosemide (CAN), Furoside (CAN), Lasix, Lasix Special (CAN), Myrosemide, Novosemide (CAN), Uritol (CAN) Class and Category Chemical class: Sulfonamide Therapeutic class: Antihypertensive, diuretic Pregnancy category: C Indications and Dosages To reduce edema caused by cirrhosis, heart failure, and renal disease, including nephrotic syndrome Oral solution, tablets Adults. 20 to 80 mg as a single dose, increased by 20 to 40 mg every 6 to 8 hr until desired response occurs. Maximum: 600 mg daily. Children. 2 mg/kg as a single dose, increased by 1 to 2 mg/kg every 6 to 8 hr until desired response occurs. Maximum: 6 mg/kg/dose. I.V. infusion, I.V. or I.M. injection Adults. 20 to 40 mg as a single dose, increased by 20 mg every 2 hr until desired response occurs. Children. 1 mg/kg as a single dose, increased by 1 mg/kg every 2 hr until desired response occurs. Maximum: 6 mg/kg/dose. DOSAGE ADJUSTMENT Initial single dose limited to 20 mg for elderly patients.To manage mild to moderate hypertension, as adjunct to treat acute pulmonary edema and hypertensive crisis Oral solution, tablets Adults. Initial: 40 mg b.i.d., adjusted until desired response occurs. Maximum: 600 mg daily. I.V. infusion or injection Adults with normal renal function. 40 to 80 mg as a single dose over several minutes. Adults with acute renal failure or pulmonary edema. 100 to 200 mg as a single dose over several minutes. Route Onset Peak Duration P.O. 20 to 60 min 1 to 2 hr 6 to 8 hr I.V. 5 min In 30 min 2 hr I.M. 30 min Unknown 2 hr Mechanism of Action Inhibits sodium and water reabsorption in the loop of Henle and increases urine formation. As the body's plasma volume decreases, aldosterone production increases, which promotes sodium reabsorption and the loss of potassium and hydrogen ions. Furosemide also increases the excretion of calcium, magnesium, bicarbonate, ammonium, and phosphate. By reducing intra-cellular and extracellular fluid volume, the drug reduces blood pressure and decreases cardiac output. Over time, cardiac output returns to normal. Incompatibilities Don't mix furosemide (a milky, buffered alkaline solution) with highly acidic solutions. in Contraindications Anuria unresponsive to furosemide; hypersensitivity to furosemide, sulfonamides, or their components Interactions Drugs ACE inhibitors: Possibly first-dose hypotension aminoglycosides, cisplatin: Increased risk of ototoxicity amiodarone: Increased risk of arrhythmias from hypokalemia chloral hydrate: Possibly diaphoresis, hot flashes, and hypertension digoxin: Increased risk of digitalis toxicity related to hypokalemia insulin, oral antidiabetic drugs: Increased blood glucose level lithium: Increased risk of lithium toxicity NSAIDs: Possibly decreased diuresis phenytoin, probenecid: Possibly decreased therapeutic effects of furosemide propranolol: Possibly increased blood propranolol level thiazide diuretics: Possibly profound diuresis and electrolyte imbalances Activities alcohol use: Possibly increased hypotensive and diuretic effects of furosemide Adverse Reactions CNS: Dizziness, fever, headache, paresthesia, restlessness, vertigo, weakness CV: Orthostatic hypotension, shock, thromboembolism, thrombophlebitis EENT: Blurred vision, oral irritation, ototoxicity, stomatitis, tinnitus, transient hearing loss (rapid I.V. injection), yellow vision ENDO: Hyperglycemia GI: Abdominal cramps, anorexia, constipation, diarrhea, gastric irritation, hepatocellular insufficiency, indigestion, jaundice, nausea, pancreatitis, vomiting GU: Bladder spasms, glycosuria HEME: Agranulocytosis (rare), anemia, aplastic anemia (rare), azotemia, hemolytic anemia, leukopenia, thrombocytopenia MS: Muscle spasms SKIN: Bullous pemphigoid, erythema multiforme, exfoliative dermatitis, photosensitivity, pruritus, purpura, rash, urticaria Other: Allergic reaction (interstitial nephritis, necrotizing vasculitis, systemic vasculitis), dehydration, hyperuricemia, hypochloremia, hypokalemia, hyponatremia, hypovolemia Nursing Considerations WARNING Use furosemide cautiously in patients with advanced hepatic cirrhosis, especially those who also have a history of electrolyte imbalance or hepatic encephalopathy; drug may lead to lethal hepatic coma. Obtain patient's weight before and periodically during furosemide therapy to monitor fluid loss. For once-a-day dosing, give drug in the morning so patient's sleep won't be interrupted by increased need to urinate. Prepare drug for infusion with normal saline solution, lactated Ringer's solution, or D5W. Administer drug slowly I.V. over 1 to 2 minutes to prevent ototoxicity. Expect patient to have periodic hearing tests during prolonged or high-dose I.V. therapy. Monitor blood pressure and hepatic and renal function as well as BUN, blood glucose, and serum creatinine, electrolyte, and uric acid levels, as appropriate. Be aware that elderly patients are more susceptible to hypotensive and electrolyte-altering effects and thus are at greater risk for shock and thromboembolism. If patient is at high risk for hypokalemia, give potassium supplements along with furosemide, as prescribed. Expect to discontinue furosemide at maximum dosage if oliguria persists for more than 24 hours. Be aware that furosemide may worsen left ventricular hypertrophy and adversely affect glucose tolerance and lipid metabolism. Notify prescriber if patient experiences hearing loss, vertigo, or ringing, buzzing, or sense of fullness in her ears. Drug may need to be discontinued. Patient Teaching Instruct patient to take furosemide at the same time each day to maintain therapeutic effects. Urge her to take it as prescribed, even if she feels well. Instruct patient to take the last dose of furosemide several hours before bedtime to avoid sleep interruption from diuresis. If patient receives once-daily dosing, advise her to take the dose in the morning to avoid sleep disturbance caused by nocturia. Advise patient to change position slowly to minimize effects of orthostatic hypotension and to take furosemide with food or milk to reduce GI distress. Caution patient about drinking alcoholic beverages, standing for prolonged periods, and exercising in hot weather because these actions increase the hypotensive effect of furosemide. Emphasize the importance of weight and diet control, especially limiting sodium intake. Unless contraindicated, urge patient to eat more high-potassium foods and to take a potassium supplement, if prescribed, to prevent hypokalemia. Instruct patient to keep follow-up appointments with prescriber to monitor progress. Urge her to notify prescriber about persistent, severe nausea, vomiting, and diarrhea because they may cause dehydration. Inform diabetic patient that furosemide may increase blood glucose level, and advise her to check her blood glucose level frequently.

gemfibrozil

Apo-Gemfibrozil (CAN), Gen-Fibro (CAN), Lopid, Novo-Gemfibrozil (CAN), Nu-Gemfibrozil (CAN) Class and Category Chemical class: Fibric acid derivative, phenoxypentanoic acid Therapeutic class: Antihyperlipidemic Pregnancy category: C Indications and Dosages As adjunct (with diet) to treat hyperlipidemia types IIb, IV, and V Capsules, tablets Adults. 600 mg a.c. b.i.d. Route Onset Peak Duration P.O. 2 to 5 days 4 wk Unknown Mechanism of Action May decrease hepatic triglyceride production by reducing VLDL synthesis, inhibiting peripheral lipolysis, and decreasing hepatic extraction of free fatty acids. Gemfibrozil also may inhibit synthesis and increase clearance of apolipoprotein B, a carrier molecule for VLDL. In addition, it may accelerate turnover and removal of total cholesterol from the liver while increasing cholesterol excretion in the feces. As a result of these actions, triglyceride, total cholesterol, and VLDL levels decrease; the HDL level increases; and the LDL level is unaffected. Contraindications Gallbladder disease, hepatic or severe renal dysfunction, hypersensitivity to gemfibrozil or its components Interactions Drugs chenodiol, ursodiol: Decreased effectiveness of gemfibrozil HMG-CoA reductase inhibitors: Increased risk of rhabdomyolysis and acute renal failure oral anticoagulants: Increased anticoagulation repaglinide: Increased serum repaglinide level Adverse Reactions CNS: Chills, fatigue, headache, hypoesthesia, paresthesia, seizures, somnolence, syncope, vertigo CV: Vasculitis EENT: Blurred vision, cataracts, hoarseness, retinal edema, taste perversion GI: Abdominal or epigastric pain, cholelithiasis, colitis, diarrhea, flatulence, heartburn, hepatoma, nausea, pancreatitis, vomiting GU: Decreased male fertility, dysuria, impotence HEME: Anemia, bone marrow hypoplasia, eosinophilia, leukopenia, thrombocytopenia MS: Arthralgia, back pain, myalgia, myasthenia, myopathy, myositis, rhabdomyolysis, synovitis RESP: Cough SKIN: Eczema, jaundice, pruritus, rash Other: Anaphylaxis, angioedema, increased risk of bacterial and viral infections, lupus-like symptoms, weight loss Nursing Considerations Monitor serum triglyceride and cholesterol levels, as appropriate. Periodically review CBC and liver function test results during therapy, as ordered. If serum triglyceride and cholesterol levels don't improve within 3 months, expect to switch to a different drug, as prescribed. Patient Teaching Instruct patient to take gemfibrozil 30 minutes before breakfast and 30 minutes before dinner. Advise patient to take a missed dose as soon as he remembers, unless it's nearly time for the next dose. Caution against doubling the dose. Stress the importance of a low-fat diet, regular exercise, alcohol avoidance, and smoking cessation, as appropriate. Caution patient to avoid hazardous activities until drug's CNS effects are known. Instruct patient to notify prescriber if he experiences chills; cough; fever; hoarseness; lower back, side, or muscle pain; painful or difficult urination; severe abdominal pain with nausea and vomiting; tiredness; or weakness. If patient also takes an oral anticoagulant, urge him to report unusual bleeding or bruising; anticoagulant dosage may need to be reduced. Advise patient to keep scheduled appointments with prescriber to check progress.

metoprolol tartrate

Apo-Metoprolol (CAN), Betaloc (CAN), Betaloc Durules (CAN), Lopresor (CAN), Lopresor SR (CAN), Lopressor, Novometoprol (CAN) Class and Category Chemical class: Beta1-adrenergic antagonist Therapeutic class: Antianginal, antihypertensive, MI prophylaxis and treatment Pregnancy category: C Indications and Dosages To manage hypertension, alone or with other antihypertensives E.R.tablets (metoprolol succinate) Adults. Initial: 25 to 100 mg daily, adjusted weekly as prescribed. Maximum: 400 mg daily. E.R.tablets (metoprolol tartrate) Adults. Maintenance: 100 to 400 mg daily to maintain blood pressure control after therapeutic level has been achieved with immediate-release tablets. Tablets (metoprolol tartrate) Adults. Initial: 100 mg daily, adjusted weekly as prescribed. Maximum: 450 mg daily as a single dose or in divided doses. To treat acute MI or evolving acute MI Tablets (metoprolol tartrate), I.V. injection (metoprolol tartrate) Adults. Initial: 5 mg by I.V. bolus every 2 min for 3 doses followed by 50 mg P.O. for patients who tolerate total I.V. dose (or 25 to 50 mg P.O. for patients who can't tolerate total I.V. dose) every 6 hr for 48 hr, starting 15 min after final I.V. dose; after 48 hr, 100 mg b.i.d. followed by maintenance dosage. Maintenance: 100 mg P.O. b.i.d. for at least 3 mo. To treat angina pectoris and chronic stable angina E.R.tablets (metoprolol succinate) Adults. 100 mg daily, increased weekly as prescribed. Maximum: 400 mg daily as a single dose or in divided doses. E.R.tablets (metoprolol tartrate) Adults. Initial: 100 mg daily, adjusted weekly as prescribed. Maximum: 450 mg daily. Tablets (metoprolol tartrate) Adults. Initial: 50 mg b.i.d., adjusted weekly as prescribed. Maximum: 450 mg daily. To treat stable, symptomatic (New York Heart Association [NYHA] Class II or III), ischemic, hypertensive, or cardiomyopathic heart failure E.R.tablets (metoprolol succinate) Adults. Initial: 25 mg daily (NYHA Class II) or 12.5 mg daily (NYHA Class III or more severe heart failure) for 2 wk. Then dosage doubled every 2 wk as tolerated. Maximum: 200 mg daily. Route Onset Peak Duration P.O. 60 min 1 to 2 hr Unknown P.O. (E.R.) Unknown 6 to 12 hr Unknown I.V. Unknown 20 min Unknown Mechanism of Action Inhibits stimulation of beta1-receptor sites, located mainly in the heart, resulting in decreased cardiac excitability, cardiac output, and myocardial oxygen demand. These effects help relieve angina. Metoprolol also helps reduce blood pressure by decreasing renal release of renin. Contraindications Acute heart failure; pulse less than 45 beats/ minute; cardiogenic shock; hypersensitivity to metoprolol, its components, or other beta blockers; pheochromocytoma; second- or third-degree AV block; severe peripheral arterial disorders; sick sinus syndrome Interactions Drugs aluminum salts, barbiturates, calcium salts, cholestyramine, colestipol, NSAIDs, rifampin, salicylates, sulfinpyrazone: Decreased therapeutic effects of metoprolol amiodarone, digoxin, diltiazem, verapamil: Increased risk of complete AV block calcium channel blockers: Increased risk of heart failure and increased effects of both drugs cimetidine: Increased blood metoprolol level clonidine: Increased risk of hypotension; increased risk of rebound hypertension when clonidine is discontinued digoxin: Decreased heart rate and slowed atrioventricular conduction estrogens: Possibly decreased antihypertensive effect of metoprolol general anesthetics: Increased risk of hypotension and heart failure insulin, oral antidiabetic drugs: Decreased blood glucose control, possibly masking of signs and symptoms of hypoglycemia (by metoprolol) lidocaine: Increased risk of lidocaine toxicity MAO inhibitors: Risk of hypertension neuromuscular blockers: Possibly enhanced and prolonged neuromuscular blockade other antihypertensives: Additive hypotensive effect phenothiazines: Possibly increased blood levels of both drugs propafenone: Increased blood level and half-life of metoprolol sympathomimetics, xanthines: Possibly decreased therapeutic effects of both drugs Foods all foods: Increased bioavailability of metoprolol Adverse Reactions CNS: Anxiety, confusion, depression, dizziness, drowsiness, fatigue, hallucinations, headache, insomnia, weakness CV: Angina, arrhythmias (including AV block and bradycardia), chest pain, decreased HDL level, increased triglyceride levels, gangrene of extremity, heart failure, hypertension, orthostatic hypotension EENT: Nasal congestion, rhinitis, taste disturbance GI: Constipation, diarrhea, hepatitis, nausea, vomiting GU: Impotence HEME: Leukopenia, thrombocytopenia MS: Arthralgia, back pain, myalgia RESP: Bronchospasm, dyspnea SKIN: Diaphoresis, photosensitivity, rash, urticaria, worsening of psoriasis Nursing Considerations Use metoprolol with extreme caution in patients with bronchospastic disease who don't respond to or can't tolerate other antihypertensive therapy. Expect to give smaller doses more often to avoid higher plasma levels that occur with longer dosage intervals. Use cautiously in patients with hypertension or angina who have congestive heart failure because beta blockers such as metoprolol can further depress myocardial contractility, causing heart failure to worsen. For patient with acute MI who can't tolerate initial dosage or who delays treatment, start with maintenance dosage, as prescribed and tolerated. Before starting therapy for heart failure, expect to give a diuretic, an ACE inhibitor, and digoxin to stabilize patient. Be aware that the metoprolol dosage for heart failure is highly individualized. Monitor patient for signs and symptoms of worsening heart failure during dosage increases. If heart failure worsens, expect to increase the diuretic dosage and possibly decrease the metoprolol dosage or temporarily discontinue drug, as prescribed. Be aware that the metoprolol dosage shouldn't be increased until signs and symptoms of worsening heart failure have been stabilized. If patient with heart failure develops symptomatic bradycardia, expect to decrease the metoprolol dosage. WARNING If dosage exceeds 400 mg daily, monitor patient for bronchospasm and dyspnea because metoprolol competitively blocks beta2-adrenergic receptors in bronchial and vascular smooth muscles. WARNING When substituting metoprolol for clonidine, expect to gradually reduce clonidine dosage and increase metoprolol dosage over several days. Giving these drugs together causes additive hypotensive effects. Patients who take metoprolol may be at risk for AV block. If AV block results from depressed AV node conduction, prepare to administer appropriate drug, as prescribed, or assist with insertion of temporary pacemaker. Check for signs of poor glucose control in patient with diabetes mellitus. Metoprolol may interfere with therapeutic effects of insulin and oral antidiabetic drugs. It also may mask evidence of hypoglycemia, such as palpitations, tachycardia, and tremor. Monitor patient with peripheral vascular disease for evidence of arterial insufficiency (pain, pallor, and coldness in affected extremity) because metoprolol can precipitate or aggravate peripheral vascular disease. Be aware that abrupt withdrawal of drug can precipitate thyroid storm in patient with hyperthyroidism or thyrotoxicosis. WARNING Expect to taper dosage when drug is discontinued; stopping abruptly can cause myocardial ischemia, MI, ventricular arrhythmias, or severe hypertension, especially in patients with cardiac disease. Patient Teaching Instruct patient to take metoprolol with food at the same time each day—once daily for E.R. tablets. Inform him that he may halve tablets but not chew or crush them. Advise patient to notify prescriber if pulse rate falls below 60 beats/minute or is significantly lower than usual. Urge diabetic patient to check his blood glucose level often during metoprolol therapy. Caution patient not to stop metoprolol abruptly.

Clozapine

Clozaril, Fazaclo Class and Category Chemical class: Dibenzodiazepine derivative Therapeutic class: Antipsychotic Pregnancy category: B Indications and Dosages To treat severe schizophrenia unresponsive to standard drugs; to reduce risk of recurrent suicidal behavior in schizophrenia or schizoaffective disorders Orally disintegrating tablets, tablets Adults. Initial: 12.5 mg once or twice daily. Increased by 25 to 50 mg daily to 300 to 450 mg daily by the end of 2 wk. Subsequent dosage adjustments shouldn't exceed 100 mg once or twice per wk. Maximum: 900 mg daily. Route Onset Peak Duration P.O. 1 to 6 hr Unknown 4 to 12 hr Mechanism of Action May produce antipsychotic effects by interfering with dopamine binding to dopamine—especially D4—receptors in the limbic region of the brain and by antagonizing adrenergic, cholinergic, histaminic, and serotoninergic receptors. Contraindications Angle-closure glaucoma, coma, history of clozapine-induced agranulocytosis or severe granulocytopenia, hypersensitivity to clozapine or its components, myeloproliferative disorders, severe CNS depression, uncontrolled epilepsy, WBC count below 3,500/mm3 Interactions Drugs anticholinergics: Potentiated anticholinergic effects benzodiazepines, psychotropics: Additive hypotensive effects; increased risk of cardiopulmonary collapse bone marrow depressants: Potentiated myelosuppressive effects carbamazepine, phenytoin: Decreased blood clozapine level cimetidine, citalopram, erythromycin: Increased blood clozapine level CNS depressants: Increased CNS depression digoxin, warfarin: Increased blood level of digoxin and warfarin; displacement of clozapine from its binding site lithium: Increased risk of confusion, dyskinesia, neuroleptic malignant syndrome, and seizures selective serotonin reuptake inhibitors: Markedly increased blood clozapine level; increased risk of adverse effects and leukocytosis Activities alcohol use: Increased CNS depression Adverse Reactions CNS: Agitation, akinesia, anxiety, ataxia, confusion, depression, dizziness, drowsiness, dystonia, fatigue, fever, headache, hyperkinesia, hypokinesia, insomnia, lethargy, myoclonic jerks, neuroleptic malignant syndrome, nightmares, restlessness, rigidity, sedation, seizures, sleep disturbance, slurred speech, syncope, tardive dyskinesia, tremor, vertigo, weakness CV: Cardiac arrest, cardiomyopathy, chest pain, deep vein thrombosis, ECG changes, hypercholesterolemia, hypertension, hyper-triglyceridemia, hypotension, myocarditis, orthostatic hypotension, tachycardia EENT: Blurred vision, dry mouth, increased nasal congestion, increased salivation, pharyngitis, tongue numbness or soreness ENDO: Ketoacidosis, severe hyperglycemia GI: Abdominal discomfort, anorexia, constipation, diarrhea, elevated liver function test results, heartburn, nausea, vomiting GU: Abnormal ejaculation; urinary frequency, urgency, and incontinence; urine retention HEME: Agranulocytosis, eosinophilia, leukopenia, neutropenia MS: Back or leg pain, muscle spasm or weakness, myalgia RESP: Dyspnea, respiratory arrest SKIN: Rash Other: Weight gain Nursing Considerations Use clozapine cautiously in patients with hepatic, renal, or cardiovascular disease and in elderly patients with dementia-related psychosis because they have increased risk of serious or fatal adverse reactions. WARNING Rarely, clozapine causes severe or life-threatening adverse reactions, such as agranulocytosis, cardiac or respiratory arrest, deep vein thrombosis, myocarditis (especially in first month), neuroleptic malignant syndrome, and severe hyperglycemia with ketoacidosis in nondiabetic patients. It also may cause seizures and tardive dyskinesia. Monitor patient closely. WARNING Check patient's baseline WBC count and absolute neutrophil count (ANC) before therapy and weekly for first 6 months. If WBC count is at least 3,500/mm3 and ANC at least 2,000/mm3, check every 2 weeks for next 6 months. If counts remain stable, expect to continue checking every 4 weeks thereafter. If patient develops mild leukopenia (WBCs 3,000 to 3,500/mm3) or granulocytopenia (ANC 1,500 to 2,000/mm3), expect to check counts twice weekly until normal. In moderate leukopenia (WBCs 2,000 to 3,000/mm3) or granulocytopenia (ANC 1,000 to 1,500/mm3), expect to stop drug temporarily and check counts daily until improved. Follow manufacturer's direction for resuming drug and monitoring. In severe leukopenia (WBCs less than 2,000/mm3) or granulocytopenia (ANC less than 1,000/mm3), expect to stop drug permanently and monitor counts daily, then as specified by manufacturer. Monitor temperature. A transient increase above 100.4° F (38° C) may occur, most often within the first 3 weeks of therapy. When therapy ends, expect to check WBC count and ANC weekly for at least 4 weeks or until WBC count is 3,500/mm3 or more and ANC is 2,000/mm3 or more. Monitor patienst, especially male patients and younger patients, for dystonia, particularly during the first few days of treatment. Be alert for complaints of neck spasms, which sometimes may progress to throat tightness, trouble swallowing or breathing, and tongue protrusion. Patient Teaching Tell patient that he'll receive only a 1-week supply at a time. Tell patient taking orally disintegrating tablets (Fazaclo) to leave tablet in blister pack until ready to take it. Tell him to peel foil back to remove tablet (rather than pushing tablet through foil) and then to immediately place tablet in mouth and let it dissolve before swallowing. Explain that no water is needed. Inform patient that he'll need weekly blood tests. Review evidence of dyscrasias (fatigue, fever, sore throat, weakness); urge patient to report them to prescriber if they occur. Instruct patient to avoid hazardous activities until drug's CNS effects are known. Advise patient to rise slowly from lying or sitting positions to minimize orthostatic hypotension. If patient stops drug for more than 2 days, stress need to contact prescriber for instructions; dosage will need to be changed. Tell patient to consult prescriber before using alcohol or taking OTC drugs. Advise female patients to notify prescriber if pregnancy occurs or is suspected.

Methylphenidate hydrochloride

Concerta, Daytrana Ritalin LA, Metadate, Metadate CD, Metadate ER, Methylin, Methylin ER, PMS-Methylphenidate (CAN), Riphenidate (CAN), Ritalin, Ritalin-LA, Ri-talin SR (CAN), Ritalin-SR Class, Category, and Schedule Chemical class: Piperidine derivative Therapeutic class: CNS stimulant Pregnancy category: C Controlled substance schedule: II Indications and Dosages To treat attention-deficit hyperactivity disorder (ADHD) Capsules, E.R.tablets, oral solution, S.R.tablets, tablets Adults and adolescents. 5 to 20 mg b.i.d. or t.i.d. Maximum: 90 mg daily. Children ages 6 to 12. 5 mg b.i.d. before breakfast and lunch; increased by 5 to 10 mg daily at 1-wk intervals. Maximum: 60 mg daily. E.R. once-daily tablets (Concerta) Adults and adolescents. 18 mg daily; increased in 18-mg increments at 1-wk intervals. Maximum: 72 mg daily, not to exceed 2 mg/kg daily. Children ages 6 to 12. 18 mg daily. Maximum: 54 mg daily. E.R. once-daily capsules (Metadate CD) Children age 6 and over. 20 mg daily. Dosage titrated to 40 or 60 mg daily based on individual response. Maximum: 60 mg daily. Transdermal patch Children ages 6 to 12. Initial: 10-mg (12.5-cm) patch worn 9 hr daily; after 1 wk, increased to 15-mg (18.75-cm) patch worn 9 hr daily; after 1 more wk, increased to 20-mg (25-cm) patch worn 9 hr daily; after 1 more wk, increased to 30-mg (37.5-cm) patch worn 9 hr daily. Maximum: 30-mg (37.5-cm) patch worn 9 hr daily. To treat narcolepsy Oral solution, tablets Adults and adolescents. 5 to 20 mg b.i.d. or t.i.d. Maximum: 90 mg daily. Route Onset Peak Duration P.O. (tablets) Unknown Unknown 3 to 6 hr P.O. (E.R., S.R.) Unknown Unknown About 8 hr P.O. (E.R. once-daily) Unknown Unknown About 12 hr Mechanism of Action Blocks the reuptake mechanism of dopaminergic neurons in the cerebral cortex and subcortical structures of the brain, including the thalamus, decreasing motor restlessness and improving concentration. Methylphenidate also may trigger sympathomimetic activity. This action produces increased motor activity, alertness, mild euphoria, and decreased fatigue in patients with narcolepsy. Contraindications Angina pectoris, anxiety, cardiac arrhythmias, depression, fructose intolerance, glaucoma, glucose-galactose malabsorption, heart failure, hypersensitivity to methylphenidate or its components, hyperthyroidism, motor tics, recent MI, severe agitation, severe hypertension, sucrase-isomaltase insufficiency, tension, thyrotoxicosis, Tourette's syndrome or family history of it, use of halogenated anethestics, use within 14 days of an MAO inhibitor Interactions Drugs anticholinergics: Possibly increased anticholinergic effects of both drugs anticonvulsants, oral anticoagulants, phenylbutazone, tricyclic antidepressants: Inhibited metabolism and increased blood levels of these drugs diuretics, antihypertensives: Decreased therapeutic effects of these drugs halogenated anesthetics: Possibly sudden decrease in blood pressure during surgery MAO inhibitors: Possibly increased adverse effects of methylphenidate, possibly severe hypertension Foods caffeine: Increased methylphenidate effects Adverse Reactions CNS: Agitation, aggressiveness, anxiety, confusion, depression, dizziness, dyskinesia, emotional lability, fever, hallucinations, headache, hyperactivity, insomnia, irritability, ischemic neurologic defects (reversible), mania, motor tics, nervousness, paresthesia, psychosis, sedation, seizures, stroke, suicidal ideation, transient mood depression, tension, tremor, Tourette's syndrome, vertigo CV: Angina, arrhythmias, bradycardia, chest pain, extrasystoles, hypertension, hypotension, MI, palpitations, Raynaud's phenomenon, sudden death, tachycardia EENT: Accommodation abnormality, blurred vision, diplopia, dry mouth or throat, mydriasis, pharyngitis, rhinitis, sinusitis, vision changes ENDO: Dysmenorrhea, growth suppression in children with long-term use GI: Abdominal pain, anorexia, constipation, diarrhea, dyspepsia, hepatotoxicity, nausea, vomiting GU: Decreased libido HEME: Anemia, decreased platelet count, leukopenia, pancytopenia, thrombocytopenia, thrombocytopenic purpura MS: Arthralgia, myalgia, muscle tightness or twitching RESP: Increased cough, upper respiratory tract infection SKIN: Allergic contact dermatitis, alopecia, application site reactions (transdermal patch), diaphoresis, erythema multiforme, exfoliative dermatitis, pruritus, rash, urticaria Other: Anaphylaxis, angioedema, physical and psychological dependence, weight loss Nursing Considerations WARNING Be aware that methylphenidate may induce CNS stimulation and psychosis and may worsen behavior disturbances and thought disorders in patients who already have psychosis. Use drug cautiously in patients with psychosis. Keep in mind that, when signs and symptoms of ADHD occur with acute stress reactions or with preexisting structural cardiac abnormalities or other serious heart problems, treatment with methylphenidate usually isn't indicated because of possible worsened reaction or sudden death. Monitor children and adolescents for first-time psychotic or manic symptoms. If present, notify prescriber and expect drug to be discontinued. WARNING Know that the E.R. tablet form (Concerta) shouldn't be administered to patients with esophageal motility disorders; drug may cause GI obstruction because the tablet doesn't change shape in GI tract. Monitor blood pressure and pulse rate to detect hypertension and excessive stimulation. Notify prescriber if you detect such signs. For patient with hypertension, expect to increase antihypertensive dosage or add another antihypertensive to existing regimen. WARNING Watch for signs of physical or psychological dependence. Methylphenidate's abuse potential is similar to that of amphetamines; use cautiously in patients with a history of drug abuse. Stopping drug abruptly after long-term use may unmask dysphoria, paranoia, severe depression, or suicidal thoughts. Monitor growth in children. Report failure to grow or gain weight, and expect to stop drug. Watch patient closely (especially children, adolescents, and young adults), for suicidal tendencies, particularly when therapy starts and dosage changes, because depression may worsen temporarily during these times possibly leading to suicidal ideation. Patient Teaching Stress need to take drug exactly as prescribed because misuse may cause serious adverse cardiovascular reactions, including sudden death. If patient uses transdermal form, teach him to apply patch to a clean, dry location in his hip area 2 hours before an effect is needed and to remove it 9 hours after application. Caution patient to avoid applying patch to skin that is oily, damaged, or irritated and to avoid the waistline, where clothing may dislodge patch. Tell patient to rotate application sites between hips. Instruct patient to apply patch immediately after opening the pouch and removing the protective liner. Tell him to press patch firmly in place with the palm of his hand for about 30 seconds. Reassure patient that exposing site to water shouldn't cause patch to fall off. If a patch does fall off, explain that a new patch may be applied but that the total exposure time for the day shouldn't exceed 9 hours. Tell patient not to chew or crush E.R. tablets. Advise patient to take tablets at least 6 hours before bedtime to avoid insomnia and to take E.R. once-daily tablets in the morning. Advise patient taking E.R. once-daily tablets (Concerta) that he may notice intact tablet in stool. Explain that drug is slowly released from nonabsorbable tablet shell. Tell patient taking capsule form to swallow it whole or sprinkle contents onto a tablespoon of applesauce and take immediately, followed by a liquid such as water. Direct patient to notify prescriber about excessive nervousness, fever, insomnia, palpitations, rash, or vomiting. Warn patient with seizure disorder that drug may cause seizures. Inform parents of children on long-term therapy that drug may delay growth. Urge family or caregiver to watch patient closely for suicidal tendencies, especially when therapy starts or dosage changes and particularly if patient is a child, teenager, or young adult.

nitrogycerine

Deponit, Minitran, Nitro-Bid, Nitrocot, Nitro-Dur, Nitrogard, Nitroglyn E-R, Nitroject, Nitrol, Nitrolingual, NitroMist, Nitrong SR, Nitro-par, Nitrostat, Nitro-time, Transderm-Nitro, Tridil Class and Category Chemical class: Nitrate Therapeutic class: Antianginal, antihypertensive, vasodilator Pregnancy category: C Indications and Dosages To prevent or treat angina E.R. buccal tablets Adults. 1 mg every 5 hr while awake. E.R. capsules Adults. 2.5, 6.5, or 9 mg every 12 hr. Frequency of doses increased to every 8 hr based on patient's response. E.R.tablets Adults. 2.6 or 6.5 mg every 12 hr. Frequency of doses increased to every 8 hr based on patient's response. S.L.tablets Adults. 0.3 to 0.6 mg, repeated every 5 min. Maximum: 3 tabs in 15 min or 10 mg daily. Transdermal ointment Adults. 1" to 2" (15 to 30 mg) every 8 hr. Frequency of doses increased to every 6 hr if angina occurs between doses. Maximum: 5" (75 mg)/application. Transdermal patch Adults. 0.1 to 0.8 mg/hr, worn 12 to 14 hr. Translingual spray Adults. For treatment, 1 or 2 metered doses (0.4 or 0.8 mg) onto or under tongue, repeated every 5 min as needed. For prevention, 1 or 2 metered doses (0.4 or 0.8 mg) onto or under tongue 5 to 10 minutes before activities that could lead to acute attack. To prevent or treat angina, to manage hypertension or heart failure I.V. infusion Adults. 5 mcg/min, increased by 5 mcg/min every 3 to 5 min to 20 mcg/min, as prescribed, and then by 10 to 20 mcg/min every 3 to 5 min until desired effect occurs. Route Onset Peak Duration P.O. (buccal) 3 min Unknown 5 hr P.O. (E.R.) 20 to 45 min Unknown 8 to 12 hr I.V. 1 to 2 min Unknown 3 to 5 min S.L. 1 to 3 min Unknown 30 to 60 min Trans- dermal (ointment) In 30 min Unknown 4 to 8 hr Trans- dermal (patch) In 30 min Unknown 8 to 24 hr Trans- lingual 2 to 4 min Unknown 30 to 60 min Mechanism of Action May interact with nitrate receptors in vascular smooth-muscle cell membranes. This interaction reduces nitroglycerin to nitric oxide, which activates the enzyme guanylate cyclase, increasing intracellular formation of cGMP. The increased cGMP level may relax vascular smooth muscle by forcing calcium out of muscle cells, causing vasodilation. Venous dilation decreases venous return to the heart, reducing left ventricular end-diastolic pressure and pulmonary artery wedge pressure. Arterial dilation decreases systemic vascular resistance, systolic arterial pressure, and mean arterial pressure. Thus, nitro-glycerin reduces preload and afterload, decreasing myocardial workload and oxygen demand. It also dilates coronary arteries, increasing blood flow to ischemic myocardial tissue. Incompatibilities Don't administer I.V. nitroglycerin through I.V. bags or tubing made of polyvinyl chloride. Don't mix drug with other solutions. in Contraindications Acute MI (S.L.), angle-closure glaucoma, cerebral hemorrhage, concurrent use of phosphodiesterase inhibitors, constrictive pericarditis (I.V.), head trauma, hypersensitivity to adhesive in transdermal form, hypersensitivity to nitrates, hypotension (I.V.), hypovolemia (I.V.), inadequate cerebral circulation (I.V.), increased intracranial pressure, orthostatic hypotension, pericardial tamponade, severe anemia Interactions Drugs acetylcholine, norepinephrine: Possibly decreased therapeutic effects of these drugs heparin: Possibly decreased anticoagulant effect of heparin (I.V. nitroglycerin) opioid analgesics, other antihypertensives, vasodilators: Possibly increased orthostatic hypotension phosphodiesterase inhibitors, such as sildenafil: Possibly severe hypotensive effect of nitroglycerin sympathomimetics: Possibly decreased anti-anginal effect of nitroglycerin and increased risk of hypotension Activities alcohol use: Possibly increased orthostatic hypotension Adverse Reactions CNS: Agitation, anxiety, dizziness, headache, insomnia, restlessness, syncope, weakness CV: Arrhythmias (including tachycardia), edema, hypotension, orthostatic hypotension, palpitations EENT: Blurred vision, burning or tingling in mouth (buccal, S.L. forms), dry mouth GI: Abdominal pain, diarrhea, indigestion, nausea, vomiting GU: Dysuria, impotence, urinary frequency HEME: Methemoglobinemia MS: Arthralgia RESP: Bronchitis, pneumonia SKIN: Contact dermatitis (transdermal forms), flushing of face and neck, rash Nursing Considerations Use nitroglycerin cautiously in elderly patients, especially those who are volume depleted or taking several medications, because of the increased risk of hypotension and falls. Hypotension may be accompanied by angina and paradoxical slowing of the heart rate. Notify prescriber if these occur, and provide appropriate treatment, as ordered. Plan a nitroglycerin-free period of about 10 hours each day, as prescribed, to maintain therapeutic effects and avoid tolerance. Place E.R. buccal tablets in buccal pouch with patient in sitting or lying position. Don't break or crush E.R. tablets or capsules. Have patient swallow them whole with a full glass of water. Place S.L. tablet under patient's tongue and make sure it dissolves completely. Be sure to remove cotton from S.L. tablet container to allow quick access to the drug. When applying transdermal ointment, apply correct amount on dose-measuring paper. Then place paper on hairless area of body and spread in a thin even layer over an area at least 2 inches by 3 inches. Don't place on cuts or irritated areas. Wash your hands after application. Rotate sites. Store at room temperature. Open transdermal patch package immediately before use. Apply patch to hairless area, and press edges to seal. Rotate sites. Store at room temperature. If patient needs cardioversion or defibrillation, remove transdermal patch. Don't shake translingual spray container before administering. Have patient inhale and hold her breath, and then spray drug under or on her tongue. Be aware that I.V. nitroglycerin should be diluted only in D5W or normal saline solution and shouldn't be mixed with other infusions. The pharmacist should add drug to a glass bottle, not a container made of polyvinyl chloride. Don't use a filter because plastic absorbs drug. Administer with infusion pump. Check vital signs before every dosage adjustment and frequently during therapy. Frequently monitor heart and breath sounds, level of consciousness, fluid intake and output, and pulmonary artery wedge pressure, if possible. Store premixed containers in the dark; don't freeze them. WARNING Assess patient for signs and symptoms of overdose, such as confusion, diaphoresis, dyspnea, flushing, headache, hypotension, nausea, palpitations, tachycardia, vertigo, vision changes, and vomiting. Treat as prescribed by removing nitroglycerin source, if possible; elevating the legs above heart level; and administering an alpha-adrenergic agonist, such as phenylephrine, as prescribed, to treat severe hypotension. Patient Teaching Teach patient to recognize signs and symptoms of angina pectoris, including chest fullness, pain, and pressure, possibly with sweating and nausea. Pain may radiate down left arm or into neck or jaw. Inform female patients and those with diabetes mellitus or hypertension that they may experience only fatigue and shortness of breath. Instruct patient to read and follow package instructions to obtain full benefits of drug. To prevent drug tolerance, inform patient that prescriber may order a 10- to 12-hour drug-free period at night (or at another time if she has chest pain at night or in the morning). Instruct patient to swallow E.R. tablets or capsules whole—not to break, crush, or chew them—with a full glass of water. For sublingual or buccal use, advise patient to place a tablet under her tongue or in her buccal pouch when angina starts and then to sit or lie down. Instruct her not to swallow drug, but to let it dissolve. Explain that moisture in her mouth helps drug absorption. If angina doesn't subside, instruct patient to place another tablet under her tongue or in her buccal pouch after 5 minutes and to repeat, if needed, for three doses total. If pain doesn't subside after 20 minutes, urge patient to call 911 or another emergency service. Advise patient to carry S.L. tablets in their original brown bottle in a purse or jacket pocket, but not one that will be affected by body heat. Instruct her to store drug in a dry place at room temperature and to discard cotton from container. Advise her to discard and replace S.L. tablets after 6 months. Advise patient using transdermal ointment or patch to rotate sites to avoid skin sensitization. Inform patient that swimming or bathing doesn't affect transdermal forms but that hot tubs, saunas, prolonged hot showers, electric blankets, and magnetic therapy over site may increase drug absorption and cause dizziness and hypotension. Caution against inhaling translingual spray. Before first use, tell patient to press actuator button 10 times to prime container and then hold container upright with forefinger on top of actuator button. Tell her to open her mouth, bring container as close as possible, press actuator button firmly to release spray onto or under her tongue, and release button and immediately close her mouth. Remind her to replace plastic cover on container and to not spit out the drug or rinse her mouth for 5 to 10 minutes. Tell her to reprime container by pressing actuator button twice if container hasn't been used for more than 6 weeks. Remind patient to periodically check level of fluid in container. If it reaches the top or middle hole on side of container, more should be obtained. Caution patient not to let level of liquid get to bottom of hole. Inform patient that nitroglycerin commonly causes headache, which typically resolves after a few days of continuous therapy. Suggest taking acetaminophen, as needed. Advise patient to notify prescriber immediately about blurred vision, dizziness, and severe headache. Suggest that patient change positions slowly to minimize orthostatic hypotension. Advise patient to avoid hazardous activities until drug's CNS effects are known. Urge patient to avoid alcohol and erectile dysfunction drugs during therapy.

hydromorphone

Dilaudid, Dilaudid-5, Dilaudid-HP, Hydrostat IR, Palladone, PMS-Hydromorphone (CAN), PMS-Hydromorphone Syrup (CAN) Class, Category, and Schedule Chemical class: Phenanthrene derivative, semisynthetic opioid derivative Therapeutic class: Analgesic Pregnancy category: C Controlled substance schedule: II Indications and Dosages To relieve moderate to severe pain Oral solution Adults. 2.5 to 10 mg every 3 to 6 hr, p.r.n. Tablets Adults. 2 mg every 3 to 6 hr, p.r.n. Increased to 4 mg or more every 4 to 6 hr, if indicated. E.R. capsules Adults. Highly individualized and dependent on patient's previous total daily 24-hour opioid use. Once dosage is determined, drug is given daily. I.V. injection Adults. 1 mg every 3 hr, p.r.n. I.M. or subcutaneous injection Adults. 1 or 2 mg every 3 to 6 hr, p.r.n. Increased to 3 or 4 mg every 4 to 6 hr, if needed for severe pain. Suppositories Adults. 3 mg every 4 to 8 hr, p.r.n. Route Onset Peak Duration P.O. 30 min 1.5 to 2 hr 4 hr I.V. 10 to 15 min 15 to 30 min 2 to 3 hr I.M. 15 min 30 to 60 min 4 to 5 hr SubQ 15 min 30 to 90 min 4 hr P.R. 30 min Unknown 4 hr Mechanism of Action May bind with opioid receptors in the spinal cord and higher levels in the CNS. In this way, hydromorphone is believed to stimulate mu and kappa receptors, thus altering the perception of and emotional response to pain. Contraindications Acute asthma; hypersensitivity to hydromorphone, other narcotics, or their components; increased intracranial pressure; severe respiratory depression; upper respiratory tract obstruction Interactions Drugs anticholinergics: Increased risk of ileus, severe constipation, or urine retention antihypertensives, diuretics, guanadrel, guanethidine, mecamylamine: Increased risk of orthostatic hypotension barbiturate anesthetics: Increased sedative effect of hydromorphone belladonna alkaloids, difenoxin and atropine, diphenoxylate and atropine, kaolin pectin, loperamide, paregoric: Increased risk of CNS depression and severe constipation buprenorphine, butorphanol, dezocine, nalbuphine, pentazocine: Possibly potentiated or suppressed symptoms of spontaneous narcotic withdrawal CNS depressants, other opioid analgesics: Additive CNS depression and hypotension hydroxyzine: Increased analgesia, CNS depression, and hypotension metoclopramide: Decreased effect of metoclopramide on GI motility naloxone: Possibly withdrawal symptoms in physically dependent patients naltrexone: Possibly prolonged respiratory depression or cardiac arrest neuromuscular blockers: Additive CNS depression Activities alcohol use: Increased CNS depression Adverse Reactions CNS: Anxiety, confusion, dizziness, drowsiness, euphoria, hallucinations, headache, nervousness, restlessness, sedation, somnolence, tremor, weakness CV: Hypertension, orthostatic hypotension, palpitations, tachycardia EENT: Blurred vision, diplopia, dry mouth, laryngeal edema, laryngospasm, nystagmus, tinnitus GI: Abdominal cramps, anorexia, biliary tract spasm, constipation, hepatotoxicity, nausea, vomiting GU: Dysuria, urine retention RESP: Dyspnea, respiratory depression, wheezing SKIN: Diaphoresis, flushing Other: Injection site pain, redness, and swelling; physical and psychological dependence Nursing Considerations To improve analgesic action, give hydromorphone before pain becomes intense. Give I.V. form by direct injection over at least 2 minutes. For infusion, mix drug with D5W, normal saline solution, or Ringer's solution. Monitor for respiratory depression when using I.V. route. Keep resuscitation equipment and naloxone nearby. Rotate I.M. and subcutaneous injection sites. Monitor effectiveness of hydromorphone in relieving pain; consult prescriber as needed. Assess patient for constipation. Monitor patient for signs of physical dependence or abuse. Anticipate that drug may mask or worsen gallbladder pain. Be aware that all other around-the-clock opioid analgesics should be stopped when E.R. capsules are prescribed. Expect to give immediate-release nonopioid analgesics for exacerbations of pain and for preventing pain during certain activities. Patient Teaching Instruct patient to take hydromorphone exactly as prescribed and before pain is severe. Advise patient to take drug with food to avoid GI distress. Tell patient not to break open or chew E.R. capsules but to swallow them whole. Instruct patient to refrigerate suppositories. Caution patient to avoid alcohol and OTC drugs during therapy, unless prescriber approves. Instruct patient to report constipation, difficulty breathing, severe nausea, or vomiting. Inform patient that drug may cause drowsiness and sedation. Advise her to avoid potentially hazardous activities until drug's CNS effects are known. Tell patient to change position slowly to minimize effects of orthostatic hypotension. To avoid withdrawal, instruct physically dependent patient not to stop taking hydromorphone abruptly.

methadone

Dolophine, Methadose Class, Category, and Schedule Chemical class: Phenylheptylamine Therapeutic class: Synthetic opiate agonist Pregnancy category: C Controlled substance schedule: II Indications and Dosages To manage opioid detoxification Dispersible tablets, oral concentrate, I.M. or subcutaneous injection Adults. Initial: 15 to 40 mg daily or as needed. Usual: Dosage individualized based on clinical response. Maximum: 120 mg daily. Children. Dosage individualized based on age and size. Maximum: 120 mg daily. To maintain opioid abstinence Dispersible tablets, oral concentrate Adults. Dosage individualized based on clinical response. Maximum: 120 mg daily. Children. Dosage individualized based on age and size. Maximum: 120 mg daily. To treat severe or chronic pain Oral concentrate, oral solution Adults. 5 to 20 mg every 4 to 8 hr. Dosage increased or dosing interval decreased, as prescribed and as needed. Maximum: 120 mg/day. Children. Dosage individualized based on age and size. TABLETS, I.M. OR SUBCUTANEOUS INJECTION Adults. 2.5 to 10 mg every 3 to 4 hr as needed. For chronic pain, dosage and dosing interval may be adjusted, as prescribed and as needed. Children. Dosage individualized based on age and size. Route Onset Peak Duration P.O. 30 to 60 min 1.5 to 2 hr 4 to 6 hr I.M. 10 to 20 min 1 to 2 hr 4 to 5 hr Mechanism of Action Binds with and activates opioid receptors (primarily mu receptors) in the spinal cord and in higher levels of the CNS to produce analgesia and euphoric effects. Contraindications Acute or postoperative pain, acute or severe asthma, chronic respiratory disease, diarrhea associated with pseudomembranous colitis or poisoning, hypersensitivity to methadone or its components, respiratory depression, severe inflammatory bowel disease Interactions Drugs ammonium chloride, ascorbic acid, potassium, sodium phosphate: May precipitate methadone withdrawal symptoms amitriptyline, chloripramine, nortriptyline: Increased CNS and respiratory depression anticholinergics: Possibly severe constipation leading to ileus; urine retention antiemetics, general anesthetics, hypnotics, phenothiazines, sedatives, tranquilizers: Possibly coma, hypotension, respiratory depression, and severe sedation antihistamines, choral hydrate, glutethimide, MAO inhibitors, methocarbamol: Increased CNS and respiratory depressant effects of methadone antihypertensives, hypotension-producing drugs: Increased hypotension, risk of orthostatic hypotension azole antifungals, macrolide antibiotics: Increased or prolonged opioid effect buprenorphine: Decreased therapeutic effect of methadone, increased respiratory depression, possibly withdrawal symptoms calcium channel blockers, class Ia and class III antiarrhythmics, diuretics, laxatives, mineralocorticoid hormones, neuroleptics, tricyclic antidepressants: Increased risk of electrolyte disturbances and prolonged QT interval carbamazepine, phenobarbital, St. John's wort: Possibly precipitation of withdrawal symptoms cimetidine: Increased analgesic and CNS and respiratory depressant effects of methadone desipramine: Increased plasma desipramine level didanosine, stavudine: Decreased plasma levels of these drugs diuretics: Decreased diuresis efavirenz, nevirapine, ritonavir, ritonavir and lopinavir: Decreased blood methadone level hydroxyzine: Increased analgesic, CNS depressant, and hypotensive effects of methadone loperamide, paregoric: Increased CNS depression, possibly severe constipation MAO inhibitors: Possibly increased risk of severe adverse reactions metoclopramide: Possibly antagonized metoclopramide effects on GI motility mixed agonist-antagonist analgesics: Possibly withdrawal symptoms naloxone: Antagonized analgesic and CNS and respiratory depressant effects of methadone, and possibly withdrawal symptoms naltrexone: Possibly induction or worsening of withdrawal symptoms if methadone given within 7 days before naltrexone neuromuscular blockers: Increased or prolonged respiratory depression opioid analgesics (such as alfentanil and sufentanil): Increased CNS and respiratory depression, increased hypotension phenytoin, rifampin: May precipitate withdrawal symptoms selective serotonin reuptake inhibitors: Possibly increased blood methadone levels and increased risk of methadone toxicity zidovudine: Increased blood zidovudine level and risk of toxicity Activities alcohol use: Increased CNS and respiratory depression, possibly hypotension Adverse Reactions CNS: Agitation, amnesia, anxiety, asthenia, coma, confusion, decreased concentration, delirium, delusions, depression, dizziness, drowsiness, euphoria, fever, hallucinations, headache, insomnia, lethargy, light-headedness, malaise, psychosis, restlessness, sedation, seizures, syncope, tremor CV: Bradycardia, cardiac arrest, cardiomyopathy, edema, heart failure, hypotension, orthostatic hypotension, palpitations, phlebitis, prolonged QT interval, shock, tachycardia, torsades de pointes, T-wave inversion on ECG, ventricular fibrillation or tachycardia EENT: Blurred vision, diplopia, dry mouth, glossitis, laryngeal edema or laryngospasm (allergic), miosis, nystagmus, rhinitis GI: Abdominal cramps or pain, anorexia, biliary tract spasm, constipation, diarrhea, dysphagia, elevated liver function test results, gastroesophageal reflux, hiccups, ileus and toxic megacolon (in patients with inflammatory bowel disease), indigestion, nausea, vomiting GU: Amenorrhea, decreased ejaculate potency, decreased libido, difficult ejaculation, impotence, prolonged labor, urinary hesitancy, urine retention HEME: Anemia, leukopenia, thrombocytopenia MS: Arthralgia RESP: Apnea, asthma exacerbation, atelectasis, bronchospasm, depressed cough reflex, hypoventilation, pulmonary edema, respiratory arrest and depression, wheezing SKIN: Diaphoresis, flushing Other: Allergic reaction; facial edema; hypokalemia; hypomagnesemia; injection site edema, pain, rash, or redness; physical and psychological dependence; weight gain; withdrawal symptoms Nursing Considerations Before giving methadone, make sure opioid antagonist and equipment for administering oxygen and controlling respiration are nearby. Before therapy begins, assess patient's current drug use, including all prescription and OTC drugs. WARNING Give drug cautiously to patients at risk for a prolonged QT interval, such as those with cardiac hypertrophy, hypokalemia, or hypomagnesemia; those with a history of cardiac conduction abnormalities; and those taking diuretics or medications that affect cardiac conduction. Dilute oral concentrate with water or another liquid to a volume of at least 30 ml, but preferably to 90 ml or more, before administration. Dissolve dispersible tablets in water or another liquid before administration. Monitor patient for expected excessive drowsiness, unsteadiness, or confusion during first 3 to 5 days of therapy, and notify prescriber if effects continue to worsen or persist beyond this time. WARNING Monitor respiratory and circulatory status carefully and at frequent intervals during methadone therapy because respiratory depression, circulatory depression, respiratory arrest, shock, hypotension, and cardiac arrest are potential hazards of therapy. Monitor children frequently for respiratory depression and paradoxical CNS excitation because of their increased sensitivity to drug. Assess patient for excessive or persistent sedation; dosage may need to be adjusted. Monitor for drug tolerance, especially in patients with a history of chronic drug abuse, because methadone can cause physical and psychological dependence. Monitor patient for pain because maintenance dosage doesn't provide pain relief; patients who have developed a tolerance to opiate agonists, including those with chronic cancer pain, may require a higher dosage. Monitor patients who are pregnant or who have liver or renal impairment for increased adverse effects from methadone because drug may have a prolonged duration and cumulative effect in these patients. Methadone may prolong labor by reducing strength, duration, and frequency of uterine contractions, so expect dosage to be tapered before third trimester of pregnancy. Breast-feeding mothers on maintenance therapy put their infants at risk of withdrawal symptoms if they abruptly stop breast-feeding or discontinue methadone therapy. Methadone also accumulates in CNS tissue, increasing the risk of seizures in infants. Check plasma amylase and lipase levels in patients who develop biliary tract spasms because levels may increase up to 15 times normal. Notify prescriber immediately of any significant or sustained increase. Monitor patients who have head injuries or other conditions that may increase intracranial pressure (ICP) because methadone may further increase ICP. Assess patient for withdrawal symptoms and tolerance to therapy because physiologic dependence can occur with long-term methadone use. Avoid abrupt discontinuation because withdrawal symptoms will occur within 3 to 4 days after last dose. Monitor patients, especially the elderly, for cardiac arrhythmias, hypotension, hypovolemia, orthostatic hypotension, and vasovagal syncope because methadone may produce cholinergic effects in patients with cardiac disease, resulting in bradycardia and peripheral vasodilation; dosage decrease may be indicated. Monitor patients with prostatic hypertrophy, urethral stricture, or renal disease for urine retention and oliguria because methadone can increase tension of detrusor muscle. Be prepared to treat patient's symptoms of anxiety, and be aware that anxiety may be confused with symptoms of opioid abstinence and that methadone doesn't have antianxiety effects. Patient Teaching Instruct patient taking oral concentrate form of methadone to dilute it with water or another liquid to a volume of at least 30 ml and preferably to 90 ml or more before administration. Instruct patient to dissolve dispersible tablets in water or other liquid before administration. Advise patient to notify prescriber of all other drugs he's currently taking and to avoid alcohol and other depressants, such as sleeping pills and tranquilizers, because they may increase drug's CNS depressant effects. Instruct patient to take drug only as prescribed and not to change dosage without prescriber approval. Inform patient that abrupt cessation of methadone therapy can precipitate withdrawal symptoms. Urge him to notify prescriber if he develops any concerns over therapy. Urge patient to notify prescriber if he experiences palpitations, dizziness, light-headedness, or syncope, which may be caused by methadone-induced arrhythmias. Instruct patient to avoid potentially hazardous activities or those that require mental alertness because methadone therapy may cause drowsiness or sleepiness. Teach patient to change positions slowly to minimize the effects of orthostatic hypotension. Instruct patient to notify prescriber of worsening or breakthrough pain because dosage may need to be adjusted. Inform parents that a child on methadone maintenance therapy may become unusually excited or restless; advise them to notify prescriber of changes in child's behavior. Instruct female patient to notify prescriber immediately if she becomes pregnant during methadone therapy because drug may cause physical dependence in fetus and withdrawal symptoms in neonate. Caution patient who is breast-feeding not to stop doing so abruptly and not to stop taking methadone without prescriber's approval because infant may experience withdrawal symptoms.

Levodopa carbidopa

Dopar, Larodopa Class and Category Chemical class: Dihydroxyphenylalanine isomer, metabolic precursor of dopamine Therapeutic class: Antidyskinetic Pregnancy category: Not rated Indications and Dosages To manage symptoms of primary Parkinson's disease, postencephalitic parkinsonism, and parkinsonism caused by CNS injury from carbon monoxide or manganese intoxication CAPSULES, TABLETS Adults and children age 12 and over. Initial: 250 mg daily in divided doses b.i.d. to q.i.d. Increased by 100 to 750 mg every 3 to 7 days, as indicated. Maximum: 8 g daily. Route Onset Peak Duration P.O. 14 to 21 days* Unknown 5 hr Mechanism of Action By supplementing a low level of endogenous dopamine, levodopa helps control alterations in voluntary muscle movement (such as tremors and rigidity) associated with Parkinson's disease. Dopamine, a neurotransmitter that's synthesized and released by neurons leading from substantia nigra to basal ganglia, is essential for normal motor function. By stimulating peripheral and central dopaminergic2 (D2) receptors on postsynaptic cells, dopamine inhibits the firing of striatal neurons (such as cholinergic neurons). In Parkinson's disease, progressive degeneration of these neurons substantially reduces the supply of intra-synaptic dopamine. Levodopa, a dopamine precursor, increases the dopamine supply in neurons, making more available to stimulate dopaminergic receptors. Contraindications Angle-closure glaucoma, history of melanoma, hypersensitivity to levodopa or its components, suspicious undiagnosed skin lesions, use within 14 days of MAO inhibitor therapy Interactions Drugs antacids: Increased blood levodopa level antihypertensives: Risk of orthostatic hypotension benzodiazepines: Possibly decreased therapeutic effects of levodopa bromocriptine: Possibly additive effects of levodopa furazolidone, MAO inhibitors, procarbazine: Risk of severe hypertension haloperidol, loxapine, molindone, papaverine, phenothiazines, phenytoin, rauwolfia alkaloids: Decreased effects of levodopa inhaled anesthetics, sympathomimetics: Increased risk of arrhythmias iron salts: Possibly decreased blood level and effectiveness of levodopa methyldopa: Possibly toxic CNS effects metoclopramide: Possibly worsening of Parkinson's disease and decreased therapeutic effects of metoclopramide pyridoxine (vitamin B6): Decreased antidys-kinetic effect of levodopa Foods high-protein food: Decreased levodopa absorption Activities cocaine use: Increased risk of arrhythmias Adverse Reactions CNS: Aggressiveness, anxiety, ataxia, confusion, delusions, dizziness, dream disturbances, dyskinesia, dystonia, euphoria, hallucinations, headache, increased tremor, insomnia, malaise, mood changes, severe depression, suicidal tendencies, syncope, weakness CV: Arrhythmias, hot flashes, orthostatic hypotension, palpitations EENT: Bitter aftertaste, blurred vision, darkened saliva, diplopia, dry mouth, increased salivation, mydriasis, tooth clenching and grinding GI: Abdominal pain, anorexia, constipation, diarrhea, flatulence, GI bleeding, hepatotoxicity, hiccups, indigestion, nausea, vomiting GU: Darkened urine, priapism, urine retention SKIN: Darkened sweat, diaphoresis, rash Nursing Considerations Expect to discontinue levodopa 6 to 8 hours before surgery to avoid interactions with anesthetics. Observe patient for mental or behavioral changes and suicidal tendencies. Notify prescriber immediately if they occur. Monitor for muscle twitching and blepharospasm (eyelid spasm), which are early signs of overdose. Report these signs immediately. Expect patient to be tested for acromegaly and diabetes during long-term levodopa therapy. Also expect to monitor hematopoietic, hepatic, and renal function. Patient Teaching Advise patient to take levodopa with meals if she experiences adverse GI reactions. Because protein impairs drug absorption, instruct patient to avoid high-protein meals during levodopa therapy and to distribute protein intake equally throughout the day. Caution patient to avoid excessive use of vitamins and fortified cereals that contain vitamin B6 or iron, which can reduce levodopa's effects. Instruct patient to report fainting, increased muscle tremor, difficult urination, and severe or persistent nausea and vomiting. Urge patient to continue taking drug as prescribed even if results of therapy aren't evident immediately. Inform patient that saliva, sweat, and urine may darken but that this isn't harmful. Direct patient to protect drug from heat, light, and moisture and to discard darkened pills because they have lost their potency. Advise patient to change position slowly to minimize effects of orthostatic hypotension. Caution male patient about risk of priapism (persistent, painful erection), and urge him to seek medical help immediately if it occurs.

Nicotine patch

Habitrol, Nicoderm, NicoDerm CQ, Nicotrol, ProStep Class and Category Chemical class: Pyridine alkaloid Therapeutic class: Smoking cessation adjunct Pregnancy category: C (nicotine polacrilex), D (other forms of nicotine) Indications and Dosages To relieve nicotine withdrawal symptoms, including craving Chewing gum Adults. Initial: 2 or 4 mg p.r.n. or every 1 to 2 hr, adjusted to complete withdrawal by 4 to 6 mo. Maximum: 30 pieces of 2-mg gum daily or 20 pieces of 4-mg gum daily. Nasal solution Adults. 1 to 2 sprays (1 to 2 mg) in each nostril/hr. Maximum: 5 mg/hr or 40 mg daily for up to 3 mo. Oral inhalation Adults and adolescents. 6 to 16 cartridges (24 to 64 mg) daily for up to 12 wk; then dosage gradually reduced over 12 wk or less. Maximum: 16 cartridges (64 mg) daily for 6 mo. Transdermal system Adults. Initial: 14 to 22 mg daily, adjusted to lower-dose systems over 2 to 5 mo. Mechanism of Action Binds selectively to nicotinic-cholinergic receptors at autonomic ganglia, in the adrenal medulla, at neuromuscular junctions, and in the brain. By providing a lower dose of nicotine than cigarettes, this drug reduces nicotine craving and withdrawal symptoms. Contraindications Hypersensitivity to nicotine, its components, or components of transdermal system; life-threatening arrhythmias; nonsmokers; recovery from acute MI; severe angina pectoris; skin disorders (transdermal); temporomandibular joint disease (chewing gum) Interactions Drugs acetaminophen, beta blockers, imipramine, insulin, oxazepam, pentazocine, theophylline: Possibly increased therapeutic effects of these drugs (chewing gum, nasal spray, transdermal system) alpha blockers, bronchodilators: Possibly increased therapeutic effects of these drugs (chewing gum, transdermal system) bupropion: Potentiated therapeutic effects of nicotine, possibly increased risk of hypertension sympathomimetics: Possibly decreased therapeutic effects of these drugs (chewing gum, transdermal system) theophylline, tricyclic antidepressants: Possibly altered pharmacologic actions of these drugs (oral inhalation) Foods acidic beverages (citrus juices, coffee, soft drinks, tea, wine): Decreased nicotine absorption from gum if beverages consumed within 15 minutes before or while chewing gum caffeine: Increased effects of caffeine (chewing gum, nasal spray, transdermal system) Adverse Reactions CNS: Dizziness, dream disturbances, drowsiness, headache, irritability, light-headedness, nervousness (chewing gum, transdermal system); amnesia, confusion, difficulty speaking, headache, migraine headache, paresthesia (nasal spray); chills, fever, headache, paresthesia (oral inhalation) CV: Arrhythmias (all forms); hypertension (chewing gum, transdermal system); peripheral edema (nasal spray) EENT: Increased salivation, injury to teeth or dental work, mouth injury, pharyngitis, stomatitis (chewing gum); altered taste, dry mouth (chewing gum, transdermal system); altered smell and taste, burning eyes, dry mouth, earache, epistaxis, gum disorders, hoarseness, lacrimation, mouth and tongue swelling, nasal blisters, nasal irritation or ulceration, pharyngitis, rhinitis, sinus problems, sneezing, vision changes (nasal spray); altered taste, lacrimation, pharyngitis, rhinitis, sinusitis, stomatitis (oral inhalation) GI: Eructation (chewing gum); abdominal pain, constipation, diarrhea, flatulence, increased appetite, indigestion, nausea, vomiting (chewing gum, transdermal system); abdominal pain, constipation, diarrhea, flatulence, hiccups, indigestion, nausea (nasal spray); diarrhea, flatulence, hiccups, indigestion, nausea, vomiting (oral inhalation) GU: Dysmenorrhea (chewing gum, transdermal system); menstrual irregularities (nasal spray) MS: Jaw and neck pain (chewing gum); arthralgia, myalgia (chewing gum, transdermal system); arthralgia, back pain, myalgia (nasal spray); back pain (oral inhalation) RESP: Cough (chewing gum, transdermal system); bronchitis, bronchospasm, chest tightness, cough, dyspnea, increased sputum production (nasal spray); chest tightness, cough, dyspnea, wheezing (oral inhalation) SKIN: Diaphoresis, erythema, pruritus, rash, urticaria (chewing gum, transdermal system); acne, flushing of face, pruritus, purpura, rash (nasal spray); pruritus, rash, urticaria (oral inhalation) Other: Allergic reaction (chewing gum, transdermal system); physical dependence (nasal spray); flulike symptoms, generalized pain, withdrawal symptoms (oral inhalation) Nursing Considerations When administering nicotine by oral inhalation, expect optimal effect to result from continuous puffing for 20 minutes. To avoid possible burns, remove patch before patient has an MRI. Patient Teaching Instruct patient to read and follow package instructions to obtain best results with nicotine product. Advise patient to notify prescriber about other drugs she takes. Stress that patient must stop smoking as soon as nicotine treatment starts to avoid toxicity. For chewing gum therapy, instruct patient to wait at least 15 minutes after drinking coffee, juice, soft drink, tea, or wine. Advise her to chew gum until she detects a tingling sensation or peppery taste and then to place the gum between her cheek and gum until tingling or peppery taste subsides. Then direct her to move the gum to a different site until tingling or taste subsides, repeating until she no longer feels the sensation—usually about 30 minutes. Caution against swallowing the gum. For nasal spray, tell patient to tilt her head back and spray into a nostril. Caution against sniffing, swallowing, or inhaling spray because nicotine is absorbed through nasal mucosa. Warn patient that prolonged use of nasal form may cause dependence. For oral inhalation, tell patient to use 6 to 16 cartridges daily to prevent or relieve withdrawal symptoms and craving. Starting with 1 or 2 cartridges daily yields poor success. Direct patient to inhale through device like a cigarette, puffing often for 20 minutes. For transdermal system, tell patient not to open package until just before use because nicotine is lost in the air. Advise her to apply system to clean, hairless, dry site on upper outer arm or upper body. Instruct her to change systems and rotate sites every 24 hours and not to use the same site for 7 days. To avoid possible burns, advise patient to remove patch before undergoing any MRI procedure. WARNING Urge patient to keep all unused nicotine forms safely away from children and pets and to discard used forms carefully. (Enough nicotine may remain in used systems to poison children and pets.) Instruct her to contact a poison control center immediately if she suspects that a child has ingested nicotine. Explain to patient with asthma or COPD that nicotine may cause bronchospasm. Inform patient that it may take several attempts to successfully stop smoking. Urge her to join a smoking cessation program.

Haloperidol lactate

Haldol Concentrate Class and Category Chemical class: Butyrophenone derivative Therapeutic class: Antidyskinetic, antipsychotic Pregnancy category: C (haloperidol decanoate), not rated (haloperidol, haloperidol lactate) Indications and Dosages To treat psychotic disorders Oral solution, tablets Adults and adolescents. 0.5 to 5 mg b.i.d. or t.i.d. Maximum: Usually 100 mg daily. Children ages 3 to 12. 0.05 mg/kg daily in divided doses b.i.d. or t.i.d. Increased by 0.5 mg every 5 to 7 days, if needed. Maximum: 0.15 mg/kg daily. To treat nonpsychotic behavior disorders and Tourette's syndrome Oral solution, tablets Adults and adolescents. 0.5 to 5 mg b.i.d. or t.i.d. Maximum: Usually 100 mg daily. Children ages 3 to 12. 0.05 to 0.075 mg/kg daily in divided doses b.i.d. or t.i.d. Increased by 0.5 mg every 5 to 7 days, if needed. Maximum: 0.075 mg/kg daily. To treat acute psychotic episodes I.M.injection Adults and adolescents. Initial: 2 to 5 mg followed by subsequent doses as frequently as every 60 min. Alternatively, if symptoms are controlled, dose may be repeated every 4 to 8 hr. Maximum: Usually 100 mg daily. First oral dose may be given 12 to 24 hr after last parenteral dose. To provide long-term antipsychotic therapy for patients who require parenteral therapy Long-acting I.M. (decanoate) injection Adults. Initial: 10 to 15 times the daily oral dose up to 100 mg. Repeated every 4 wk, if needed. Maximum: 300 mg/mo. Route Onset Peak Duration I.M.* Unknown 3 to 4 days† Unknown Mechanism of Action May block postsynaptic dopamine receptors in the limbic system and increase brain turnover of dopamine, producing an antipsychotic effect. Contraindications Blood dyscrasias, bone marrow depression, cerebral arteriosclerosis, coma, concurrent use of large amounts of other CNS depressants, coronary artery disease, epilepsy, hepatic dysfunction, hypersensitivity to haloperidol or its components, Parkinson's disease, severe hypertension or hypotension, severe CNS depression, subcortical brain damage Interactions Drugs amphetamines: Possibly decreased stimulant effects of amphetamines and decreased antipsychotic effect of haloperidol anticholinergics, antidyskinetics, antihistamines: Increased anticholinergic effect and risk of decreased antipsychotic effect of haloperidol anticonvulsants: Possibly decreased effectiveness of anticonvulsants and decreased blood haloperidol level bromocriptine: Possibly decreased effectiveness of bromocriptine bupropion: Lowered seizure threshold, increased risk of major motor seizure CNS depressants: Increased CNS depression and risk of respiratory depression and hypotension diazoxide: Possibly hypoglycemia dopamine (high-dose therapy): Possibly decreased vasoconstriction ephedrine: Possibly decreased vasopressor effect of ephedrine epinephrine: Possibly severe hypotension and tachycardia fluoxetine: Increased risk of severe and frequent extrapyramidal effects guanadrel, guanethidine: Decreased hypotensive effects of these drugs levodopa, pergolide: Possibly decreased therapeutic effects of these drugs lithium: Increased risk of neurotoxicity MAO inhibitors, maprotiline, tricyclic anti-depressants: Increased sedative and anticholinergic effects of these drugs metaraminol: Possibly decreased vasopressor effect of metaraminol methoxamine: Decreased vasopressor effect, shortened duration of action of methoxamine methyldopa: Possibly disorientation, slowed or difficult thought processes phenylephrine: Decreased vasopressor response to phenylephrine Activities alcohol use: Increased CNS depression and risk of respiratory depression and hypotension Adverse Reactions CNS: Agitation, anxiety, confusion, drowsiness, dystonia, euphoria, extrapyramidal reactions that may be irreversible (akathisia, pseudoparkinsonism, tardive dyskinesia), hallucinations, headache, insomnia, neuroleptic malignant syndrome, restlessness, slurred speech, tremor, vertigo CV: Cardiac arrest, hypertension, orthostatic hypotension, QT prolongation, ventricular arrythmias, tachycardia, torsades de pointes EENT: Blurred vision, dry mouth, increased salivation (all drug forms); stomatitis (oral solution) ENDO: Breast engorgement, galactorrhea GI: Constipation, nausea, vomiting GU: Decreased libido, difficult ejaculation, impotence, menstrual irregularities, urine retention HEME: Anemia, leukocytosis, leukopenia SKIN: Diaphoresis, photosensitivity, rash Other: Heatstroke, weight gain Nursing Considerations Haloperidol shouldn't be used to treat dementia-related psychosis in the elderly because of an increased mortality risk. Use haloperidol cautiously in patients with a history of prolonged QT interval, patients with uncorrected electrolyte disturbances, and patients receiving Class IA or III antiarrhythmics because of an increased risk of prolonged QT interval. Monitor elderly patients closely because they may have an increased risk of prolonged QT interval. Dilute oral solution with a beverage, such as cola or orange, apple, or tomato juice. Administer haloperidol decanoate (long-acting form prepared in sesame oil to produce slow, sustained release) by deep I.M. injection into gluteal muscle using Z-track technique and 21G needle. Don't give more than 3 ml at one site. Expect to reach a stable plasma level after third or fourth dose. If injection solution has a slight yellow discoloration, be aware that this change doesn't affect potency. Monitor for tardive dyskinesia (potentially irreversible involuntary movements) in patients receiving long-term therapy, especially elderly women who take large doses. If extrapyramidal reactions occur during the first few days of treatment, reduce dosage, as prescribed. If symptoms persist, drug may have to be discontinued. Dystonia also may occur during first few days of treatment, especially in patients receiving higher doses and in males and younger age groups. Notify prescriber. Avoid stopping haloperidol abruptly unless severe adverse reactions occur. Monitor for signs of neuroleptic malignant syndrome, a rare but possibly fatal disorder linked to antipsychotic drugs. Signs include altered mental status, arrhythmias, fever, and muscle rigidity. WARNING Sudden death, QT-interval prolongation, and torsades de pointes, although uncommon, may occur in patients receiving haloperidol despite the lack of such predisposing factors as electrolyte imbalance, concurrent therapy with drugs known to prolong QT interval, underlying cardiac abnormalities, hypothyroidism, and familial long-QT syndrome. Patient Teaching Advise patient to take haloperidol exactly as prescribed and not to stop taking it abruptly because withdrawal symptoms may occur. To prevent oral mucosal irritation, instruct patient to dilute liquid form with juice or cola before taking it. Caution patient to avoid skin contact with oral solution because it may cause a rash. Advise patient to take tablets with food or a full glass of milk or water to reduce GI distress. Instruct patient to consume adequate fluids and to take precautions against heatstroke. Urge patient not to drink alcohol during therapy. If sedation occurs, caution patient to avoid driving and other hazardous activities. Instruct patient to report repetitive movements, tremor, and vision changes.

heparin

Hepalean (CAN), Heparin Leo (CAN), Heparin Lock Flush, Liquaemin Class and Category Chemical class: Glycosaminoglycan Therapeutic class: Anticoagulant Pregnancy category: C Indications and Dosages To prevent and treat deep vein thrombosis and pulmonary embolism, to treat peripheral arterial embolism, and to prevent thromboembolism before and after cardioversion of chronic atrial fibrillation I.V. infusion or injection Adults. Loading: 35 to 70 units/kg or 5,000 units by injection. Then 20,000 to 40,000 units infused over 24 hr. Children. Loading: 50 units/kg by injection. Then 100 units/kg infused every 4 hr or 20,000 units/m infused over 24 hr. I.V. injection Adults. Initial: 10,000 units. Maintenance: 5,000 to 10,000 units every 4 to 6 hr. Children. Initial: 50 units/kg. Maintenance: 100 units/kg/dose every 4 hr. I.V. or subcutaneous injection Adults. Loading: 5,000 units I.V., then 10,000 to 20,000 units subcutaneously. Maintenance: 8,000 to 10,000 units subcutaneously every 8 hr or 15,000 to 20,000 units subcutaneously every 12 hr. To diagnose and treat disseminated intravascular coagulation (DIC) I.V. infusion or injection Adults. 50 to 100 units/kg every 4 hr. Drug may be discontinued if no improvement occurs in 4 to 8 hr. Children. 25 to 50 units/kg every 4 hr. Drug may be discontinued if no improvement occurs in 4 to 8 hr. To prevent postoperative thromboem-bolism Subcutaneous injection Adults. 5,000 units 2 hr before surgery and then 5,000 units every 8 to 12 hr for 7 days or until patient is fully ambulatory. To prevent clots in patients undergoing open-heart and vascular surgery I.V. infusion or injection Adults. 300 units/kg for procedures that last less than 60 min; 400 units/kg for procedures that last longer than 60 min. Minimum: 150 units/kg. Children. 300 units/kg for procedures that last less than 60 min. Then dosage based on coagulation test results. Minimum: 150 units/kg. To maintain heparin lock patency I.V. injection Adults. 10 to 100 units/ml heparin flush solution (enough to fill device) after each use of device. Mechanism of Action Binds with antithrombin III, enhancing antithrombin III's inactivation of the coagulation enzymes thrombin (factor IIa) and factors Xa and XIa. At low doses, heparin inhibits factor Xa and prevents the conversion of prothrombin to thrombin. Thrombin is necessary for the conversion of fibrinogen to fibrin; without fibrin, clots can't form. At high doses, heparin inactivates thrombin, preventing fibrin formation and existing clot extension. Incompatibilities Don't mix heparin with any other drug unless you have an order to do so and have checked with pharmacist. Heparin is incompatible with many drugs and solutions, especially ones that contain a phosphate buffer, sodium bicarbonate, or sodium oxalate. in Contraindications Hypersensitivity to heparin or its components; severe thrombocytopenia; uncontrolled bleeding, except in DIC Interactions Drugs antihistamines, digoxin, nicotine, tetracyclines: Decreased anticoagulant effect of heparin aspirin, NSAIDs, platelet aggregation inhibitors, sulfinpyrazone: Increased platelet inhibition and risk of bleeding cefamandole, cefoperazone, cefotetan, methimazole, plicamycin, propylthiouracil, valproic acid: Possibly hypoprothrombinemia and increased risk of bleeding chloroquine, hydroxychloroquine: Possibly thrombocytopenia and increased risk of hemorrhage ethacrynic acid, glucocorticoids, salicylates: Increased risk of bleeding and GI ulceration and hemorrhage nitroglycerin (I.V.): Possibly decreased anticoagulant effect of heparin probenecid: Possibly increased anticoagulant effect of heparin thrombolytics: Increased risk of hemorrhage Activities smoking: Decreased anticoagulant effect of heparin Adverse Reactions CNS: Chills, dizziness, fever, headache, peripheral neuropathy CV: Chest pain, thrombosis EENT: Epistaxis, gingival bleeding, rhinitis GI:, Abdominal distention and pain, hematemesis, melena nausea, vomiting GU: Hematuria, hypermenorrhea HEME: Easy bruising, excessive bleeding from wounds, thrombocytopenia MS: Back pain, myalgia, osteoporosis RESP: Dyspnea, wheezing SKIN: Alopecia, cyanosis, petechiae, pruritus, urticaria Other: Anaphylaxis; injection site hematoma, irritation, pain, redness, and ulceration Nursing Considerations Use heparin cautiously in alcoholics; menstruating women; patients over age 60, especially women; and patients with mild hepatic or renal disease or a history of allergies, asthma, or GI ulcer. WARNING Give heparin only by subcutaneous or I.V. route; I.M. use causes hema-toma, irritation, and pain. Avoid injecting any drugs by I.M. route during heparin therapy to decrease the risk of bleeding and hematoma. WARNING Don't use heparin sodium injection as a catheter lock flush because fatal medication errors have occurred in children when 1-ml heparin sodium injection vials were confused with 1-ml catheter lock flush vials. Always examine vial labels closely to ensure correct product is being used. Administer subcutaneous heparin into the anterior abdominal wall, above the iliac crest, and 5 cm (20) or more away from the umbilicus. To minimize subcutaneous tissue trauma, lift adipose tissue away from deep tissues; don't aspirate for blood before injecting drug; don't move needle while injecting drug; and don't massage the injection site before or after injection. Keep in mind that you can apply gentle pressure to the site after you withdraw the needle. Alternate injection sites, and observe for signs of bleeding and hematoma formation. To prepare heparin for continuous infusion, invert container at least six times to prevent drug from pooling. Anticipate slight discoloration of prepared solution; this doesn't indicate a change in potency. During continuous I.V. therapy, expect to obtain APTT after 8 hours of therapy. Use the arm opposite the infusion site. For intermittent I.V. therapy, expect to adjust dose based on coagulation test results performed 30 minutes earlier. Therapeutic range is typically 1.5 to 2.5 times the control. Bleeding is the major adverse effect of heparin therapy. Take safety precautions to prevent bleeding, such as having patient use a soft-bristled toothbrush and an electric razor. Bleeding may occur at any site and also may indicate an underlying problem, such as GI or urinary tract bleeding. Other sites of bleeding that could be fatal and require immediate attention includes adrenal, ovarian, and retroperitoneal hemorrhage. Monitor blood test results and observe for signs of bleeding, such as ecchymosis, epistaxis, hematemesis, hematuria, melena, and petechiae. If platelet count drops below 1000,000/mm3 or recurrent thrombosis develops, notify prescriber and expect heparin to be discontinued. Make sure all health care providers know that patient is receiving heparin. Keep protamine sulfate on hand to use as an antidote for heparin. Be aware that each milligram of protamine sulfate neutralizes 100 units of heparin. Be aware that prescriber may order oral anticoagulants before discontinuing heparin to avoid increased coagulation caused by heparin withdrawal. Heparin may be discontinued when full therapeutic effect of oral anticoagulant is achieved. Know that women over age 60 have the highest risk of hemorrhage during therapy. Watch closely if patient is receiving heparin therapy and nitroglycerin I.V. because PTT may decrease and then rebound after nitroglycerin is discontinued. Monitor PTT closely, and be prepared to adjust heparin dose, as prescribed. WARNING Be aware that delayed-onset, heparin-induced thrombocytopenia may occur several weeks after heparin is discontinued and may progress to venous and arterial thromboses. Various heparin products contain the preservative benzyl alcohol, which isn't recommended for children under age 1 month because it may cause gasping syndrome, which may be fatal. Patient Teaching Explain that heparin can't be taken orally. Inform patient about the increased risk of bleeding; urge her to avoid injuries and to use a soft-bristled toothbrush and an electric razor. Urge patient to report any abnormal sign or symptom to prescriber, even weeks after heparin has been discontinued, because of the potential for delayed adverse reactions. Advise patient to avoid drugs that interact with heparin, such as aspirin and ibuprofen. Instruct patient and family to watch for and report abdominal or lower back pain, black stools, bleeding gums, bloody urine, excessive menstrual bleeding, nosebleeds, and severe headaches. Explain that temporary hair loss may occur. Advise patient to wear or carry appropriate medical identification.

fosinopril sodium

Monopril Class and Category Chemical class: Phosphinic acid derivative Therapeutic class: Antihypertensive, vasodilator Pregnancy category: C (first trimester), D (later trimesters) Indications and Dosages To manage blood pressure, alone or with other antihypertensives Tablets Adults. Initial: 10 mg daily. Maintenance: 20 to 40 mg daily. Maximum: 80 mg daily. To treat heart failure Tablets Adults. 10 mg daily. Route Onset Peak Duration P.O. 1 hr 2 to 6 hr 24 hr Mechanism of Action May reduce blood pressure by affecting renin-angiotensin-aldosterone system. By inhibiting angiotensin-converting enzyme, fosinopril:prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor that also stimulates the adrenal cortex to secrete aldosteronemay inhibit renal and vascular production of angiotensin IIdecreases serum angiotensin II level and increases serum renin activity, which decreases aldosterone secretion, slightly increasing the serum potassium level and fluid lossdecreases vascular tone and blood pressureinhibits aldosterone release, which reduces sodium and water reabsorption and increases their excretion, further reducing blood pressure. Contraindications Hypersensitivity to fosinopril, other ACE inhibitors, or their components Interactions Drugs allopurinol, bone marrow depressants, procainaminde, systemic corticosteroids: Increased risk of potentially fatal neutropenia or agranulocytosis antacids: Impaired fosinopril absorption cyclosporine, potassium-sparing diuretics, potassium supplements: Increased risk of hyperkalemia diuretics, other antihypertensives: Possibly additive hypotension lithium: Increased blood lithium level and risk of lithium toxicity NSAIDs: Possibly decreased antihypertensive effect of fosinopril Foods salt substitutes: Increased risk of hyperkalemia Activities alcohol use: Possibly additive hypotension Adverse Reactions CNS: Confusion, depression, dizziness, drowsiness, fatigue, fever, headache, insomnia, mood changes, sleep disturbance, syncope, tremor, vertigo, weakness CV: Angina, arrhythmias (including AV conduction disorders, bradycardia, and tachycardia), claudication, hypotension, MI, orthostatic hypotension, palpitations EENT: Dry mouth, epistaxis, eye irritation, hoarseness, rhinitis, sinus problems, taste perversion, tinnitus, vision changes GI: Abdominal distention and pain, anorexia, constipation, diarrhea, flatulence, hepatic failure, hepatitis, hepatomegaly, nausea, pancreatitis, vomiting GU: Decreased libido, flank pain, renal insufficiency, sexual dysfunction, urinary frequency MS: Arthralgia, gout, myalgia RESP: Asthma; bronchitis; bronchospasm; dry, persistent, tickling cough; dyspnea; tracheobronchitis; upper respiratory tract infection SKIN: Diaphoresis, jaundice, photosensitivity, pruritus, rash, urticaria Other: Anaphylaxis, angioedema, hyperkalemia, weight gain Nursing Considerations Monitor serum potassium level before and during fosinopril therapy, as appropriate. Observe patient being treated for heart failure for at least 2 hours after giving drug to detect hypotension or orthostatic hypotension. If either develops, notify prescriber and monitor patient until blood pressure stabilizes. Keep in mind that orthostatic hypotension is unlikely to develop in patients with a systolic blood pressure over 100 mm Hg who receive a 10-mg dose. If patient also receives an antacid, separate administration times by at least 2 hours. If patient also receives a diuretic or another antihypertensive, expect to reduce its dosage over 2 to 3 days before starting fosinopril. If blood pressure isn't controlled with fosinopril alone, other antihypertensive therapy may resume, as prescribed. If so, observe for excessive hypotension. WARNING If angioedema affects the face, glottis, larynx, limbs, lips, mucous membranes, or tongue, notify prescriber immediately. Expect to discontinue fosinopril and start appropriate therapy at once. If airway obstruction threatens, promptly give 0.3 to 0.5 ml of epinephrine solution 1:1,000 subcutaneously, as prescribed. Patient Teaching Instruct patient to take fosinopril at the same time each day to improve compliance and maintain drug's therapeutic effect. Emphasize the importance of taking fosinopril as prescribed, even if patient feels well. Caution her not to stop taking drug without consulting prescriber. Explain that drug helps control—but doesn't cure—hypertension and that patient may need lifelong therapy. WARNING Urge patient to seek immediate medical attention for difficulty breathing or swallowing, hoarseness, or swelling of the face, lips, tongue, or throat. Instruct patient to notify prescriber about persistent, severe nausea, vomiting, and diarrhea; resulting dehydration may lead to hypotension. Advise patient not to take other drugs or use salt substitutes without consulting prescriber. Encourage patient to keep scheduled appointments with prescriber to monitor blood pressure, blood test results, and effects of therapy. Caution patient about possible dizziness. To minimize effects of orthostatic hypotension, advise patient to rise slowly from a lying or sitting position and to dangle legs over bed for several minutes before standing. Reinforce prescriber's recommendations for lifestyle changes, such as smoking cessation, stress reduction, dietary improvements, alcohol avoidance, and regular exercise. If patient is a woman of childbearing age, urge her to use contraception during therapy because drug may harm fetus. Advise patient to use caution during exercise and hot weather because of the increased risk of dehydration from excessive sweating.

digoxin

Lanoxicaps, Lanoxin, Lanoxin Elixir Pediatric, Lanoxin Injection, Lanoxin Injection Pediatric, Novo-Digoxin (CAN) Class and Category Chemical class: Digitalis glycoside Therapeutic class: Antiarrhythmic, cardiotonic Pregnancy category: C Indications and Dosages To treat heart failure, atrial flutter, atrial fibrillation, and paroxysmal atrial tachycardia with rapid digitalization , I.V. Capsules Injection Adults. Loading: 10 to 15 mcg/kg in 3 divided doses every 6 to 8 hr, with first dose equal to 50% of total dose. Maintenance: 125 to 350 mcg daily once or twice daily. Children over age 10. Loading: 8 to 12 mcg/ kg in 3 or more divided doses, with first dose equal to 50% of total dose. Subsequent doses given every 6 to 8 hr. Maintenance: 2 to 3 mcg/kg once daily. Children ages 6 to 10. Loading: 15 to 30 mcg/ kg in 3 or more divided doses, with first dose equal to 50% of total dose. Subsequent doses given every 6 to 8 hr. Maintenance: 4 to 8 mcg/kg daily in 2 divided doses. Children ages 2 to 5. Loading: 25 to 35 mcg/ kg in 3 or more divided doses, with first dose equal to 50% of total dose. Subsequent doses given every 6 to 8 hr. Maintenance: 6 to 9 mcg/kg daily in 2 divided doses. Infants ages 1 to 24 months. Loading: 30 to 50 mcg/kg in 3 or more divided doses, with first dose equal to 50% of total dose. Subsequent doses every 6 to 8 hr. Maintenance: 7.5 to 12 mcg/kg daily in 2 divided doses. Full-term neonates. Loading: 20 to 30 mcg/ kg in 3 or more divided doses, with first dose equal to 50% of total dose. Subsequent doses given every 6 to 8 hr. Maintenance: 5 to 8 mcg/kg daily in 2 divided doses. Premature neonates. Loading: 15 to 25 mcg/ kg in 3 or more divided doses, with first dose equal to 50% of total dose. Subsequent doses given every 6 to 8 hr. Maintenance: 4 to 6 mcg/kg daily in 2 divided doses. Elixir, Tablets Adults. Loading: 10 to 15 mcg/kg total dose given in 3 divided doses every 6 to 8 hr, with first dose equal to 50% of total dose. Maintenance: 125 to 500 mcg daily. Children over age 10. Loading: 10 to 15 mcg/ kg total given in 3 divided doses every 6 to 8 hr, with first dose equal to 50% of total dose. Maintenance: 2.5 to 5 mcg/kg daily. Children ages 5 to 10. Loading: 20 to 35 mcg/ kg in 3 divided doses every 6 to 8 hr. Maintenance: 5 to 10 mcg/kg daily in 2 divided doses. Children ages 2 to 5. Loading: 30 to 40 mcg/ kg in 3 divided doses every 6 to 8 hr. Maintenance: 7.5 to 10 mcg/kg daily in 2 divided doses. Infants ages 1 to 24 months. Loading: 35 to 60 mcg/kg in 3 divided doses every 6 to 8 hr. Maintenance: 10 to 15 mcg/kg daily in 2 divided doses. Full-term neonates. Loading: 25 to 35 mcg/ kg in 3 divided doses every 6 to 8 hr. Maintenance: 6 to 10 mcg/kg daily in 2 divided doses. Premature neonates. Loading: 20 to 30 mcg/ kg in 3 divided doses every 6 to 8 hr. Maintenance: 5 to 7.5 mcg/kg daily in 2 divided doses. Route Onset Peak Duration P.O. 30 to 120 min 6 to 8 hr 3 to 4 days I.V. 5 to 30 min 1 to 5 hr 3 to 4 days Mechanism of Action Increases the force and velocity of myocardial contraction, resulting in positive inotropic effects. Digoxin produces antiarrhythmic effects by decreasing the conduction rate and increasing the effective refractory period of the AV node. Contraindications Hypersensitive carotid sinus syndrome, hypersensitivity to digoxin, presence or history of digitalis toxicity or idiosyncratic reaction to digoxin, ventricular fibrillation, ventricular tachycardia unless heart failure occurs unrelated to digoxin therapy Interactions Drugs adsorbent antidiarrheals, such as kaolin and pectin; bulk laxatives; cholestyramine; colestipol; oral neomycin; sulfasalazine: Inhibited digoxin absorption amiodarone, propafenone: Elevated blood digoxin level, possibly to toxic level antacids: Inhibited digoxin absorption antiarrhythmics, pancuronium, parenteral calcium salts, rauwolfia alkaloids, sympatho-mimetics: Increased risk of arrhythmias diltiazem, verapamil: Increased blood digoxin level, possibly excessive bradycardia edrophonium: Excessive slowing of heart rate erythromycin, neomycin, tetracycline: Possibly increased blood digoxin level hypokalemia-causing drugs, potassium-wasting diuretics: Increased risk of digitalis toxicity from hypokalemia indomethacin: Decreased renal clearance and increased blood level of digoxin magnesium sulfate (parenteral): Possibly cardiac conduction changes and heart block quinidine, quinine: Increased blood digoxin level spironolactone: Increased half-life and risk of adverse effects of digoxin succinylcholine: Increased risk of digoxin-induced arrhythmias sucralfate: Decreased digoxin absorption Foods high-fiber food: Inhibited digoxin absorption Adverse Reactions CNS: Confusion, depression, drowsiness, extreme weakness, headache, syncope CV: Arrhythmias, heart block EENT: Blurred vision, colored halos around objects GI: Abdominal discomfort or pain, anorexia, diarrhea, nausea, vomiting Other: Electrolyte imbalances Nursing Considerations Administer parenteral digoxin undiluted, or dilute with a fourfold or greater volume of sterile water for injection, normal saline solution, or D5W for I.V. administration. Once diluted, administer immediately. Discard if solution is markedly discolored or contains precipitate. Before giving each dose, take patient's apical pulse and notify prescriber if pulse is below 60 beats/minute (or other specified level). Monitor patient closely for signs of digitalis toxicity, such as altered mental status, arrhythmias, heart block, nausea, vision disturbances, and vomiting. If they appear, notify prescriber, check serum digoxin level as ordered, and expect to withhold drug until level is known. Monitor ECG tracing continuously. If patient has acute or unstable chronic atrial fibrillation, assess for drug effectiveness. Ventricular rate may not normalize even when serum drug level falls within therapeutic range; raising the dosage probably won't produce a therapeutic effect and may lead to toxicity. Frequently obtain ECG tracings as ordered in elderly patients because of their smaller body mass and reduced renal clearance. Elderly patients, especially those with coronary insufficiency, are more susceptible to arrhythmias—particularly ventricular fibrillation—if digitalis toxicity occurs. Monitor paptient's serum potassium level regularly because hypokalemia predisposes to digitalis toxicity and serious arrhythmias. Also monitor potassium level frequently when giving potassium salts because hyper-kalemia in patients receiving digoxin can be fatal. Patient Teaching Stress the importance of taking digoxin exactly as prescribed. Warn patient about possible toxicity from taking too much and decreased effectiveness from taking too little. Instruct patient to take digoxin at the same time each day to help increase compliance. Teach patient how to take her pulse, and instruct her to do so before each dose. Urge her to notify prescriber if pulse falls below 60 beats/minute or suddenly increases. Inform patient that small, white 0.25-mg tablets can easily be confused with other drugs. Caution against carrying digoxin in anything other than its original labeled container. Emphasize the need to use the special dropper supplied with elixir to ensure accurate dose measurement. Instruct patient to take a missed dose as soon as she remembers if within 12 hours of scheduled dose. If not, urge her to notify prescriber immediately. Urge patient to notify prescriber if she experiences adverse reactions, such as GI distress or pulse changes. Instruct patient to carry medical identification that indicates her need for digoxin. Advise patient to consult prescriber before using other drugs, including OTC products.

atorvastatin

Lipitor Class and Category Chemical class: Synthetically derived fermentation product Therapeutic class: Antihyperlipidemic, HMG-CoA reductase inhibitor Pregnancy category: X Indications and Dosages To control lipid levels as adjunct to diet in primary (heterozygous familial and nonfamilial) hypercholesterolemia and mixed dyslipidemia TABLETS Adults. Initial: 10 or 20 mg once daily; then increased according to lipid level. Maintenance: 10 to 80 mg once daily. To control lipid levels in homozygous familial hypercholesterolemia TABLETS Adults. 10 to 80 mg daily. To control lipid levels in pediatric heterozygous familial hypercholesterolemia TABLETS Adolescents and children ages 10 to 17. To reduce debilitating cardiovascular events such as stroke and MI in patients with multiple risk factors but without known coronary artery disease TABLETS Adults. 10 mg once daily. DOSAGE ADJUSTMENT FOR ALL INDICATIONS Mechanism of Action Reduces plasma cholesterol and lipoprotein levels by inhibiting HMG-CoA reductase and cholesterol synthesis in the liver and by increasing the number of LDL receptors on liver cells to enhance LDL uptake and breakdown. Contraindications Active hepatic disease, breastfeeding, hypersensitivity to atorvastatin or its components, pregnancy, unexplained persistent rise in serum transaminase level Interaction DRUGS amlodipine, cimetidine, clarithromycin, diltiazem, erythromycin, itraconazole, ritonavir with saquinavir: Increased atorvastatin level antacid, colestipol, efavirenz, rifampin: Possibly decreased blood atorvastatin level azole antifungals, colchicine, clarithromycin, cyclosporine, darunavir plus ritonavir, erythromycin, fibric acid derivatives, forsamprenavir, fosamprenavir plus ritonavir, gemfibrozil, itraconazole, lopinavir with ritonavir, niacin (at dosage used for lipid modification), nicotinic acid, ritonavir with saquinavir or tipranavir, telaprevir: Increased risk of severe myopathy or rhabdomyolysis cyclosporine: Increased atorvastatin bioavailability and risk of adverse reactions digoxin: Possibly increased blood digoxin level, causing toxicity oral contraceptives (such as ethinyl estradiol and norethindrone): Increased hormone level protease inhibitors: Possible increased blood atorvastatin level; possible increased risk of myopathy and rhabdomyolysis grapefruit juice (more than 1.2 L daily): Increased blood atorvastatin level Adverse Reactions CNS: Abnormal dreams, amnesia, asthenia, cognitive impairment, depression, dizziness, emotional lability, facial paralysis, fatigue, fever, headache, hyperkinesia, lack of coordination, malaise, paresthesia, peripheral neuropathy, somnolence, syncope, weakness CV: Arrhythmias, elevated serum CK level, orthostatic hypotension, palpitations, phlebitis, vasodilation EENT: Amblyopia, altered refraction, dry eyes, dry mouth, epistaxis, eye hemorrhage, gingival hemorrhage, glaucoma, glossitis, hearing loss, lip swelling, loss of taste, pharyngitis, sinusitis, stomatitis, taste perversion, tinnitus ENDO: Hyperglycemia or hypoglycemia GI: Abdominal or biliary pain, anorexia, colitis, constipation, diarrhea, duodenal or stomach ulcers, dysphagia, elevated liver enzymes, eructation, esophagitis, flatulence, gastroenteritis, hepatic failure, hepatitis, increased appetite, indigestion, jaundice, melena, pancreatitis, rectal hemorrhage, tenesmus, vomiting GU: Abnormal ejaculation; cystitis; decreased libido; dysuria; epididymitis; hematuria; impotence; nephritis; nocturia; renal calculi; urinary frequency, incontinence, or urgency; urine retention; vaginal hemorrhage HEME: Anemia, thrombocytopenia MS: Arthralgia, back or muscle pain, bursitis, gout, immune-mediated necrotizing myopathy, leg cramps, myalgia, myasthenia gravis, myopathy, myositis, neck rigidity, rhabdomyolysis, tendon contracture or rupture, tenosynovitis, torticollis RESP: Dyspnea, pneumonia SKIN: Acne, alopecia, contact dermatitis, diaphoresis, dry skin, ecchymosis, eczema, erythema multiforme, petechiae, photosensitivity, pruritus, rash, seborrhea, Stevens-Johnson syndrome, toxic epidermal necrolysis, ulceration, urticaria Other: Anaphylaxis, angioneurotic edema, flulike symptoms, infection, lymphadenopathy, weight gain Nursing Considerations Atorvastatin is used in patients with homozygous familial hypercholesterolemia as an adjunct to other lipid-lowering treatments or alone only if other treatments aren't available. Atorvastatin may be used with colestipol or cholestyramine for additive antihyperlipidemic effects. Know that atorvastatin should not be used in patients taking cyclosporine, gemfibrozil, tipranavir plus ritonavir, or telaprevir because of high risk for rhabdomyolysis with acute renal failure. Use atorvastatin cautiously in patients who consume substantial quantities of alcohol or have a history of liver disease because atorvasttin use increases risk of liver dysfunction. Expect atorvastatin to be used in patients without obvious coronary artery disease (CAD) but with multiple risk factors (such as age 55 or over, smoker, history of hypertension or low HDL level, or family history of early CAD). Drug is used to reduce risk of MI, angina, and adverse effects of revascularization procedures. Also expect drug to be used in patients with type 2 diabetes who have no obvious CAD but multiple risk factors, such as retinopathy, albuminuria, smoking, or hypertension. Drug is used in these patients to reduce risk of MI and stroke. Expect liver function tests to be performed before atorvastatin therapy starts and then thereafter as clinically necessary. If clinical symptoms such as jaundice and hyperbilirubinemia occurs, notify prescriber and expect atorvastatin therapy to be discontinued until cause of liver dysfunction has been identified. If no cause can be found, expect the drug to be discontinued permanently. Expect to measure lipid levels 2 to 4 weeks after therapy starts, to adjust dosage as directed, and to repeat periodically until lipid levels are within desired range. Monitor diabetic patient's blood glucose levels because atorvastatin therapy can affect blood glucose control. PATIENT TEACHING Emphasize that atorvastatin is an adjunct to-not a substitute for-a low-cholesterol diet. Tell patient to take drug at the same time each day to maintain its effects. Instruct patient to take a missed dose as soon as possible. If it's almost time for his next dose, he should skip the missed dose. Tell him not to double the dose. Instruct patient to consult prescriber before taking OTC niacin because of increased risk of rhabdomyolysis. Advise patient to notify prescriber immediately if he develops unexplained muscle pain, tenderness, or weakness, especially if accompanied by fatigue or fever. Be aware that atorvastatin is expensive. Reinforce the benefits of therapy, and urge patient to comply if possible. Advise patient with diabetes to monitor blood glucose levels closely.

enoxaparin

Lovenox Class and Category Chemical class: Low-molecular-weight heparin Therapeutic class: Antithrombotic Pregnancy category: B Indications and Dosages To prevent deep vein thrombosis (DVT) after hip or knee replacement and for continued prophylaxis after hospitalization for hip replacement Subcutaneous injection Adults. 30 mg every 12 hr, starting 12 to 24 hr after surgery for up to 14 days. Or, 40 mg daily, starting 9 to 15 hr after hip replacement surgery. Prophylaxis: 40 mg daily for 3 wk. To prevent DVT after abdominal surgery for patients with thromboembolic risk factors (over age 40, obesity, general anesthesia lasting longer than 30 minutes, cancer, or a history of DVT or pulmonary embolism) Subcutaneous injection Adults. 40 mg daily, starting 2 hr before surgery and lasting 7 to 10 days. To prevent ischemic complications of unstable angina and non-Q-wave MI Subcutaneous injection Adults. 1 mg/kg every 12 hr with 100 to 325 mg of aspirin daily for 2 to 8 days or until condition is stable. To treat acute ST-segment-elevation MI (STEMI) I.V. injection, then subcutaneous injection Adults. 30 mg I.V. as a single dose, followed by 1 mg/kg subcutaneously (maximum, 100 mg for first two doses). Then, 1 mg/kg subcutaneously every 12 hr. Route Onset Peak Duration SubQ Unknown 3 to 5 hr Up to 24 hr Mechanism of Action Potentiates the action of antithrombin III, a coagulation inhibitor. By binding with antithrombin III, enoxaparin rapidly binds with and inactivates clotting factors (primarily thrombin and factor Xa). Without thrombin, fibrinogen can't convert to fibrin and clots can't form. Incompatibilities Don't mix enoxaparin with other I.V. fluids or drugs. in Contraindications Active major bleeding; hypersensitivity to benzyl alcohol (if only the multidose vial is available), enoxaparin, heparin (including low-molecular-weight heparins), or pork products; thrombocytopenia and positive antiplatelet antibody test while taking low-molecular-weight heparins Interactions Drugs cefamandole, cefoperazone, cefotetan, plicamycin, valproic acid: Possibly increased risk of hemorrhage NSAIDs; oral anticoagulants; platelet aggregation inhibitors, such as aspirin, dipyridamole, sulfinpyrazone, and ticlopidine; thrombolytics, such as alteplase, anistreplase, streptokinase, and urokinase: Possibly increased risk of bleeding Adverse Reactions CNS: Confusion, epidural or spinal hematoma, fever, paralysis, stroke CV: Atrial fibrillation, congestive heart failure, hyperlipidemia, peripheral edema EENT: Epistaxis GI: Bloody stools, diarrhea, elevated liver function test results, hematemesis, melena, nausea, vomiting GU: Hematuria, menstrual irregularities HEME: Anemia, hemorrhage, thrombocytopenia RESP: Dyspnea, pneumonia, pulmonary edema or embolism SKIN: Cutaneous vasculitis, ecchymosis, persistent bleeding or oozing from mucous membranes or surgical wounds, pruritus, skin necrosis at injection site or distant from injection site, urticaria, vesiculobullous rash Other: Anaphylaxis; hyperkalemia; injection site erythema, hematoma, irritation, and pain Nursing Considerations Use enoxaparin with extreme caution in patients with a history of heparin-induced thrombocytopenia or increased risk of hemorrhage. Use cautiously in those with bleeding diathesis, diabetic retinopathy, hepatic or renal impairment, recent GI ulceration or hemorrhage, or uncontrolled hypertension. Expect delayed elimination in elderly patients and those with renal insufficiency. Drug isn't recommended for patients with prosthetic heart valves, especially pregnant women, because of risk of prosthetic valve thrombosis. If enoxaparin is needed, monitor patient's peak and trough anti-factor Xa levels often and adjust dosage as needed. Use multidose vials cautiously in pregnant women because benzyl alcohol may cross the placenta and cause fetal harm. Don't give drug by I.M. injection. Expect to give drug with aspirin to patient with unstable angina, STEMI, and non-Q-wave MI. To minimize risk of bleeding after vascular procedures, be careful to give enoxaparin at recommended intervals. After percutaneous revascularization procedure, it is important to achieve hemostasis at the puncture site. A closure device may be removed right away; however, if a manual compression method is used, the sheath should be removed 6 hours after last enoxaparin dose. If enoxaparin therapy will continue, give next scheduled dose no sooner than 6 to 8 hours after sheath removal. Watch closely for bleeding. Notify prescriber immediately if platelet count falls below 100,000/mm3. Expect to stop drug and start treatment if patient has a thromboembolic event, such as a stroke. Test stool for occult blood, as ordered. Keep protamine sulfate nearby in case of accidental overdose. Check serum potassium level for elevation, especially in patients with renal impairment or concurrent use of potassium-sparing diuretics. Patient Teaching Advise patient to notify prescriber about adverse reactions, especially bleeding. Instruct patient to seek immediate help for evidence of thromboembolism, such as neurologic changes and severe shortness of breath. Stress the importance of complying with follow-up visits with prescriber. Teach patient or family member how to give enoxaparin at home, if needed. Show patient how to give by deep subcutaneous injection while lying down. Instruct him not to expel air bubble from a prefilled syringe to avoid losing some of the drug. Tell him to insert the entire needle into a skin fold held between the thumb and forefinger. Remind him to alternate injection sites between the left and right anterolateral abdominal wall. To minimize bruising, caution patient not to rub the site after giving the injection. Review safe handling and disposal of syringes and needles.

fluoxetine hydrochloride

Prozac, Prozac Weekly, Sarafem Class and Category Chemical class: Phenylpropylamine derivative Therapeutic class: Antibulimic, antidepressant, antiobsessive-compulsive Pregnancy category: C Indications and Dosages To treat depression Capsules, oral solution, tablets (Prozac) Adults. Initial: 20 mg daily in the morning. Dosage increased every 4 to 8 wk as needed. Dosage greater than 20 mg daily given b.i.d. morning and noon. Maximum: 80 mg daily. Children and adolescents. Initial: 10 mg daily. Increased after 1 wk to 20 mg daily. Delayed-release capsules (Prozac Weekly) Adults. 90 mg/wk, beginning 7 days after last 20-mg daily dose. To treat obsessive-compulsive disorder Capsules, oral solution, tablets (Prozac) Adults. Initial: 20 mg daily in the morning. Dosage increased every 4 to 8 wk as needed. Dosage greater than 20 mg daily given b.i.d. morning and noon. Maximum: 80 mg daily. Children and adolescents. Initial: 10 mg daily. Dosage increased after 2 wk to 20 mg daily. Subsequent dosage increased, as needed, at intervals of at least several wk. Maintenance: 20 to 60 mg daily. DOSAGE ADJUSTMENT For lower-weight children, dosage should be increased above 10 mg daily only if clinical improvement remains insufficient after several wk. Maintenance dosage for such patients should not exceed 30 mg daily.To treat moderate to severe bulimia nervosa Capsules, oral solution, tablets (Prozac) Adults. 60 mg daily in the morning. Some patients may be prescribed a lower dose, which is titrated to 60 mg daily as tolerated. To treat panic disorder with or without agoraphobia Capsules, oral solution, tablets (Prozac) Adults. Initial: 10 mg daily. Dosage increased in 1 wk to 20 mg daily, as needed. Maximum: 60 mg daily. To treat premenstrual dysmorphic dis order Capsules (Sarafem) Adults. 20 mg daily. Dosage increased as needed. Maximum: 80 mg daily. Route Onset Peak Duration P.O.* 1 to 6 wk† Unknown Unknown Mechanism of Action Selectively inhibits reuptake of the neurotransmitter serotonin by CNS neurons and increases the amount of serotonin that's available in nerve synapses. An elevated serotonin level may result in elevated mood and, consequently, reduced depression. Contraindications Hypersensitivity to selective serotonin reuptake inhibitors or their components, use within 14 days of MAO inhibitor therapy Interactions Drugs alprazolam, diazepam: Possibly prolonged half-life of these drugs aspirin, NSAIDs, warfarin: Increased anticoagulant activity and risk of bleeding astemizole: Increased risk of serious arrhythmias buspirone: Decreased buspirone effects clozapine, fluphenazine, haloperidol, maprotiline, trazodone: Increased risk of adverse effects CYP2D6-metabolized drugs, such as antiar-rhythmics (especially flecainide, propafenone), selected antidepressants (tricyclics), antipyschotics (phenothiazines and most atypicals), thioridazine, and vinblastine: Increased plasma levels of these drugs and increased risk of serious adverse reactions linezolid, lithium, serotonergics (such as amphetamines and other psychostimulants, antidepressants, and dopamine agonists), St. John's wort, tramadol, triptans: Increased risk of serotonin syndrome MAO inhibitors: Possibly severe and life-threatening adverse effects phenytoin: Increased blood phenytoin level and risk of toxicity pimozide: Possibly bradycardia sumatriptan: Increased risk of weakness, hyperreflexia, and difficulty with coordination tryptophan: Increased risk of central and peripheral toxicity Adverse Reactions CNS:, Anxiety, chills, dream disturbances drowsiness, fatigue, fever, headache, hypomania, insomnia, mania, nervousness, restlessness, seizures, somnolence, suicidal ideation, tremor, vertigo, weakness, yawning CV: Hypotension, palpitations EENT: Abnormal vision, dry mouth, pharyngitis, sinusitis ENDO: Galactorrhea, gynecomastia, hypoglycemia, syndrome of inappropriate antidiuretic hormone secretion (SIADH) GI: Anorexia, diarrhea, indigestion, nausea GU: Decreased libido, ejaculation disorders, impotence HEME: Altered platelet function, unusual bleeding MS: Arthralgia, myalgia RESP: Dyspnea SKIN:, Diaphoresis, pruritus rash, urticaria Other: Flulike symptoms, hyponatremia, weight loss Nursing Considerations Use fluoxetine cautiously in patients with a history of seizures. WARNING Avoid giving fluoxetine within 14 days of an MAO inhibitor or starting MAO inhibitor therapy within 5 weeks of discontinuing fluoxetine. In patients taking fluoxetine for depression (especially children, adolescents, and young adults), watch closely for suicidal tendencies, particularly when therapy starts and dosage changes, because depression may worsen temporarily during those times. Monitor patient closely for evidence of GI bleeding, especially if patient takes another drug known to increase the risk, such as aspirin, an NSAID, or warfarin. Monitor patient—especially an elderly patient—for hypoosmolarity of serum and urine and for hyponatremia (headache, difficulty concentrating, memory impairment, weakness, unsteadiness), which may indicate fluoxetine-induced SIADH. To discontinue, expect to taper drug, as ordered, to minimnize adverse reactions. WARNING If patient receives another drug that raises serotonin level (such as dopamine agonists, MAO inhibitors and other antide-pressants, tryptophan, and amphetamines and other psychostimulants), watch for serotonin syndrome, a rare but serious adverse effect of selective serotonin reuptake inhibitors. Signs and symptoms include agitation, confusion, diaphoresis, diarrhea, fever, hyperactive reflexes, poor coordination, restlessness, shaking, talking or acting with uncontrolled excitement, tremor, and twitching. Monitor patient with diabetes mellitus for altered blood glucose level because drug may cause hypoglycemia during therapy and hyperglycemia when it stops. Expect to adjust dosage of antidiabetic drug, as prescribed. Expect patient to be reevaluated periodically to determine continued need for therapy. When stopping therapy, expect to taper drug to minimize adverse reactions. Patient Teaching WARNING Tell patient that drug increases the risk of serotonin syndrome, a rare but serious complication, when taken with certain other drugs. Teach patient to recognize its signs and symptoms, and advise her to notify prescriber immediately if they occur. Urge family or caregiver to watch patient closely for suicidal tendencies, especially when therapy starts or dosage changes and particularly if patient is a child, teenager, or young adult. Caution patient to avoid hazardous activities until CNS effects of drug are known. Caution against stopping drug abruptly because serious adverse effects may result. Advise patient to consult prescriber before taking OTC or prescription drugs, if a rash or hives develop, or if she becomes or intends to become pregnant during therapy. Inform patient that drug may take several weeks to achieve full effects.

butorphanol tartrate

Stadol, Stadol NS Class, Category, and Schedule Chemical class: Opioid Therapeutic class: Anesthesia adjunct, opioid analgesic Pregnancy category: C Controlled substance schedule: II Indications and Dosages To manage pain I.V. injection Adults.. 0.5 to 2 mg (usually 1 mg) every 3 to 4 hr, as needed I.M. injection Adults. 1 to 4 mg (usually 2 mg) every 3 to 4 hr, as needed.Maximum: 4 mg/single Nasal inhalation Adults. 1 spray (1 mg) in one nostril. Dose repeated after 60 to 90 min; two-dose sequence repeated every 3 to 4 hr, as needed. For severe pain, 2 sprays (1 in each nostril) every 3 to 4 hr, as needed. As adjunct to provide preoperative anesthesia I.V. or I.M. injection Adults. Individualized.Average: 2 mg 60 to 90 min before surgery. As adjunct to provide anesthesia I.V.injection Adults. Individualized.Average: 1 to 4 mg and then supplemental doses of 0.5 to 1 mg, p.r.n. Total usually required during surgery is 60 to 180 mcg/kg. Route Onset Peak Duration I.V. 2 to 3 min 30 min 2 to 4 hr I.M. 10 to 30 min 30 to 60 min 3 to 4 hr Inhalation In 15 min 1 to 2 hr 4 to 5 hr Mechanism of Action Binds with specific CNS receptors to alter the perception of and emotional response to pain. Contraindications Hypersensitivity to butorphanol or its components (including the preservative benze-thonium chloride) Interactions Drugs CNS depressants: Additive CNS depressionnasal vasoconstrictors, such as oxymetazo-line: Decreased absorption rate and delayed onset of butorphanol Activities alcohol use: Additive CNS depression Adverse Reactions CNS: Anxiety, confusion, difficulty performing purposeful movements, difficulty speaking, dizziness, euphoria, floating feeling, headache, insomnia (with nasal form), lethargy, nervousness, paresthesia, sensation of heat, somnolence, syncope, tremor, vertigo CV: Chest pain, hypotension, palpitations, tachycardia, vasodilation EENT: Blurred vision, dry mouth, ear pain, epistaxis, nasal congestion or irritation (with nasal form), pharyngitis, rhinitis, sinus congestion, sinusitis, tinnitus, unpleasant taste GI: Anorexia, constipation, epigastric pain, nausea, vomiting RESP: Apnea, bronchitis, cough, dyspnea, respiratory depression, shallow breathing, upper respiratory tract infection SKIN: Clammy skin, pruritus Nursing Considerations Use butorphanol cautiously, if at all, in patients with depression, suicidal tendency, history of drug abuse, or hepatic or renal dysfunction. Because drug can raise CSF pressure, use it cautiously, if at all, in patients with head injury. Because it can increase cardiac workload, use with extreme caution in patients with acute MI, ventricular dysfunction, or coronary insufficiency. Be aware that butorphanol has a high potential for abuse. Monitor patient after first dose of nasal form; hypotension and syncope may occur. Take safety precautions because butorphanol causes CNS depression. Assess respiratory status closely because drug causes respiratory depression. Frequently monitor blood pressure after giving drug. If severe hypertension develops (rare), stop drug at once and notify prescriber. If patient isn't narcotic-dependent, expect to administer naloxone to reverse butorphanol's effects. Patient Teaching Stress the importance of taking butorphanol exactly as prescribed because it can be addictive. Warn patient not to increase the dose or decrease the dosage interval without consulting prescriber. Advise patient to avoid hazardous activities until drug's CNS effects are known. Tell patient to avoid alcohol and other CNS depressants, including OTC drugs, while taking butorphanol because of additive adverse CNS reactions. Teach patient how to use nasal form properly. After blowing the nose to clear the nostrils, pull the clear cover from the pump unit and remove the protective clip from its neck. Prime the pump unit by placing the nozzle between the first and second fingers with the thumb on the bottom of the bottle. Then pump the sprayer unit firmly and quickly until a fine spray appears (7 or 8 strokes). Insert the spray tip about 1 cm (⅓″) into one nostril, pointing the tip toward the back of the nose. Close the other nostril with one finger and tilt the head slightly forward. Then pump the sprayer firmly and quickly by pushing down on the pump unit's finger grips and against the thumb at the bottom of the bottle. Sniff gently with the mouth closed. After spraying, remove the pump from the nose, tilt the head back, and sniff gently for a few more seconds. Then replace the protective clip and clear cover.

pentazocine

Talwin Class, Category, and Schedule Chemical class: Synthetic opioid Therapeutic class: Analgesic Pregnancy category: C Controlled substance schedule: IV Indications and Dosages To relieve moderate to severe pain I.V., I.M., or subcutaneous injection Adults. Initial: 30 mg every 3 to 4 hr, p.r.n. Maximum: 30 mg/single dose I.V., 60 mg/single dose I.M. or subcutaneously, or 360 mg/ 24 hr for all parenteral forms. To relieve obstetric pain I.V. injection Adults. 20 mg when contractions become regular; repeated 2 or 3 times every 2 to 3 hr, as prescribed. I.M. injection Adults. 30 mg as a single dose. Route Onset Peak Duration I.V. 2 to 3 15 to 2 to 3 hr 3 min 30 min I.M., SubQ 15 to 30 to 2 to 3 hr 20 min 60 min Mechanism of Action Binds with opioid receptors, primarily kappa and sigma receptors, at many CNS sites to alter the perception of and emotional response to pain. Incompatibilities Don't mix pentazocine in same syringe with a soluble barbiturate because precipitation will occur. in Contraindications Hypersensitivity to pentazocine or its components Interactions Drugs anticholinergics: Increased risk of urine retention and severe constipation antidiarrheals, antiperistaltics: Increased risk of severe constipation and CNS depression antihypertensives, diuretics, other hypotension-producing drugs: Additive hypotensive effects buprenorphine: Decreased pentazocine effectiveness, increased respiratory depression CNS depressants: Increased CNS depression, increased risk of habituation hydroxyzine, other opioid analgesics: Increased analgesia, CNS depression, and hypotensive effects MAO inhibitors: Increased risk of unpredictable, severe, even fatal adverse reactions metoclopramide: Antagonized metoclopramide effects on GI motility naloxone: Antagonized analgesic, CNS, and respiratory depressant effects of pentazocine naltrexone: Withdrawal symptoms in patients physically dependent on pentazocine neuromuscular blockers: Increased respiratory depression Activities alcohol use: Additive CNS depression and increased risk of habituation Adverse Reactions CNS: Chills, dizziness, drowsiness, euphoria, fatigue, headache, insomnia, light-headedness, nervousness, nightmares, paresthesia, restlessness, weakness CV: Hypotension, tachycardia EENT: Blurred vision, diplopia, dry mouth, laryngeal edema, laryngospasm GI: Constipation, hepatotoxicity, nausea, vomiting GU: Decreased urine output, dysuria, urinary frequency, urine retention MS: Muscle rigidity (with large doses) RESP: Atelectasis, bronchospasm, dyspnea, hypoventilation, wheezing SKIN: Diaphoresis, erythema multiforme, facial flushing, pruritus, rash, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria Other: Facial edema; injection site burning, pain, redness, or swelling; physical and psychological dependence Nursing Considerations Use pentazocine with extreme caution in patients who have head injury, intracranial lesion, or increased intracranial pressure because drug may mask neurologic evidence. Use pentazocine cautiously in patients who are physically dependent on opioid agonists because drug may prompt withdrawal symptoms; in patients with acute MI because drug's cardiovascular effects can increase cardiac workload; in patients with renal or hepatic dysfunction because drug is metabolized in the liver and excreted in urine; and in patients with respiratory conditions because drug depresses the respiratory system. When administering repeated parenteral doses, use I.M. or I.V. route when possible and as prescribed because subcutaneous route may cause severe tissue damage at injection site. Rotate I.M. sites to avoid tissue damage. After giving parenteral form, expect to taper dosage gradually, as prescribed, to reduce the risk of withdrawal symptoms. Caution patient that prolonged use of pentazocine may result in drug dependence. Advise patient to avoid potentially hazardous activities until drug's CNS effects are known. Caution patient not to use alcohol or OTC drugs without consulting prescriber. Advise patient to report possible allergic reaction, such as a rash or itching.

bupropion

Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban Class and Category Chemical class: Aminoketone derivative Therapeutic class: Antidepressant, smoking cessation adjunct Pregnancy category: C Indications and Dosages To treat depression E.R.tablets (Wellbutrin SR) Adults. Initial: 150 mg daily in the morning for 3 days; then 150 mg b.i.d. and, after several weeks, 200 mg b.i.d., as needed and tolerated. Maximum: 400 mg daily or 200 mg/dose. E.R. tablets (Wellbutrin XL) Adults. Initial: 150 mg daily in the morning for at least 3 days; then 300 mg daily and, after 4 wk, 450 mg daily, as needed and tolerated.Maximum: 450 mg daily. E.R. tablets (Aplenzin) Adults. Initial: 174 mg daily in the morning for 3 days. Then, if tolerated well, dosage increased to 348 mg daily in the morning. After 4 wk of therapy, dosage increased to 522 mg daily in the morning, if needed. Tablets Adults. Initial: 100 mg b.i.d., increased after 3 or more days to 100 mg t.i.d., as needed.Maximum: 450 mg daily or 150 mg/dose. To aid in smoking cessation E.R. tablets Adults. Initial: 150 mg daily for 3 days and then 150 mg b.i.d. for 7 to 12 wk.Maximum: 300 mg daily or 150 mg/dose. To prevent seasonal major depressive episodes in patient with seasonal affective disorder E.R. tablets Adults. Initial: 150 mg once daily in morning starting in autumn, increased after 1 wk to 300 mg once daily in morning, if tolerated and needed. Decreased to 150 mg once daily 2 wk before stopping drug in early spring. Route Onset Peak Duration P.O. 1 to 3 wk Unknown Unknown Mechanism of Action May inhibit norepinephrine, serotonin, and dopamine uptake by neurons, which significantly relieves evidence of depression. Contraindications Anorexia, bulimia, use of another form of bupropion, hypersensitivity to bupropion or its components, seizure disorder, treatment requiring abrupt discontinuation of alcohol or sedatives (including benzodiazepines), use within 14 days of an MAO inhibitor Interactions Drugs amantadine, levodopa: Increased adverse reactions to bupropion carbamazepine, cimetidine, phenobarbital, phenytoin: Increased bupropion metabolism clozapine, fluoxetine, haloperidol, lithium, loxapine, maprotiline, molindone, phenothiazines, thioxanthenes, trazodone, tricyclic antidepressants: Increased risk of major motor seizures levodopa: Increased adverse bupropion effects MAO inhibitors: Increased risk of acute bupropion toxicity nicotine: Possibly increased blood pressure warfarin: Possibly altered PT and INR; risk of hemorrhagic or thrombotic complications Activities alcohol use, recreational drug abuse: Lowered seizure threshold Adverse Reactions CNS: Agitation, akathisia, anxiety, asthenia, CNS stimulation, coma, confusion, decreased concentration or memory, delusions, dizziness, euphoria, fever, general or migraine headache, hallucinations, hostility, insomnia, irritability, nervousness, paranoia, paresthesia, seizures, sleep disorder, somnolence, stroke, suicidal ideation, syncope, tremor, vertigo CV: Arrhythmias, chest pain, complete AV block, hypertension, MI, orthostatic hypotension, palpitations, phlebitis, tachycardia, vasodilation EENT: Altered taste, amblyopia, blurred vision, dry mouth, hearing loss, increased ocular pressure, pharyngitis, sinusitis, taste perversion, tinnitus ENDO: Hyperglycemia, hypoglycemia, syndrome of inappropriate ADH secretion GI: Abdominal pain, anorexia, constipation, diarrhea, dysphagia, flatulence, GI hemorrhage, GI ulceration, hepatitis, increased appetite, intestinal perforation, nausea, pancreatitis, vomiting GU: Urinary frequency and urgency, UTI, vaginal hemorrhage HEME: Anemia, leukocytosis, leukopenia, lymphadenopathy, pancytopenia, thrombocytopenia MS: Arthralgia, arthritis, muscle twitching, myalgia, rhabdomyolysis RESP: Bronchospasm, cough, pulmonary embolism SKIN: Diaphoresis, exfoliative dermatitis, flushing, pruritus, rash, urticaria Other: Angioedema, generalized pain, hot flashes, infection, serum sicknesslike reaction, weight loss Nursing Considerations Use cautiously in patients with renal impairment; drug is excreted by the kidneys. Monitor children, adolescents, and depressed patients closely for worsened depression and increased suicide risk, especially when therapy starts or dosage changes. To reduce the risk of seizures, allow at least 4 hours between doses of bupropion tablets and 8 hours between doses of E.R. tablets. Use seizure precautions, especially in patients who take OTC stimulants or anorectics; use excessive alcohol or sedatives; are addicted to opioids, cocaine, or stimulants; take drugs that lower the seizure threshold; have a history of seizures, head trauma, or CNS tumors; have severe hepatic cirrhosis; or take insulin or an oral antidiabetic. Using transdermal nicotine with bupropion may cause hypertension. Watch closely. Patient Teaching Advise patient to take bupropion for 7 or more days before stopping smoking. Tell patient to swallow E.R. tablets whole and not to cut, crush, or chew them. Tell patient to take bupropion with food. Urge patient to avoid or minimize consuming alcohol and sedatives during therapy and not to stop drug abruptly because seizures may occur. Urge caregivers to monitor depressed patient closely for worsened depression, especially when therapy starts or dosage changes.