PathoPharm Test 2 Drugs

Niacin B3 (Niacin, Nicobid, Slo-Niacin)

-Action: Needed for conversion of fats, protein, carbohydrates by oxidation-reduction; acts directly on vascular smooth muscle, causing vasodilatation; reduces LDL, VLDL, total cholesterol, triglycerides, increases HDL -Therapeutic outcome: Decreasing cholesterol and LDL levels, B3 supplementation -Uses: Pellagra, hyperlipidemias (types IV, V), peripheral vascular disease that presents a risk for pancreatitis -Contraindications: Breastfeeding, hypersensitivity, peptic ulcer, hepatic disease, hemorrhage, severe hypotension -Precautions: Pregnancy C, breastfeeding, glaucoma, CV disease, CAD, diabetes mellitus, gout, schizophrenia Implementation -PO route • Do not break, crush, or chew ext rel products • Give with meals or milk for GI symptoms, with 81-325 mg of aspirin or NSAIDs ½ hr before dose to decrease flushing -Adverse effects CNS: Paresthesias, headache, dizziness, anxiety CV:Postural hypotension, vasovagal attacks, dysrhythmias, vasodilatation EENT:Blurred vision, ptosis GI:Nausea, vomiting, anorexia, jaundice, diarrhea, peptic ulcer, hepatotoxicity, dyspepsia, hepatitis GU:Hyperuricemia, glycosuria, hypoalbuminemia Integ:Flushing, dry skin, rash, pruritus, itching, tingling -Interactions Individual drugs Alcohol: increased flushing, pruritus, avoid use -Drug classifications Ganglionic blockers: increased postural hypotension HMG-CoA reductase inhibitors: increased myopathy, rhabdomyolysis Drug/herb Red yeast rice: increased myopathy, rhabdomyolysis -Drug/lab test Increased: bilirubin, alkaline phosphatase, liver enzymes, LDH, uric acid, glucose Decreased: cholesterol False increase: urinary catecholamines False positive: urine glucose -Nursing considerations Assessment • Assess for niacin deficiency (pellagra): nausea, vomiting, stomatitis, confusion, hallucinations before, throughout treatment • Hyperlipidemia: assess for lipid, triglyceride, cholesterol level, if using for hyperlipidemia • Assess nutrition: fat, protein, carbohydrates, nutritional analysis should be completed by dietitian • Hepatotoxicity: monitor liver function tests: AST, ALT, bilirubin, uric acid, alkaline phosphatase; blood glucose before, during treatment; liver dysfunction: clay-colored stools, itching, dark urine, jaundice • Monitor niacin levels during administration of this product • Monitor cardiac status: rate, rhythm, quality; postural hypotension, dysrhythmias • Monitor nutritional status: liver, yeast, legumes, organ meat, lean poultry; high-level niacin products should be included in the diet • Assess for CNS symptoms: headache, paresthesias, blurred vision Patient/family education • Advise patient that flushing and increase in feelings of warmth will occur several hr after taking product (PO); after 2 wk of therapy these side effects diminish • Instruct patient to remain recumbent if postural hypotension occurs; to rise slowly from sitting or recumbency • Caution patient to abstain from alcohol if product is prescribed for hyperlipidemia • Caution patient to avoid sunlight if skin lesions are present • Hepatotoxicity: Advise patient to report clay-colored stools, anorexia, yellow eyes/skin, dark urine Evaluation Positive therapeutic outcome • Decreased lipid levels • Warm extremities • Absence of numbness in extremities -DRUG ALERT Niacin (Niaspan) Instruct patient that flushing (especially of face and neck) may occur within 20 minutes after taking drug and may last for 30 to 60 minutes. -Can premedicate with aspirin or NSAID 30 minutes before to reduce flushing.

Chlorambucil (Leukeran)

-Alkylating Agents -chemotherapy drug -Damage DNA by causing breaks in the double-stranded helix. If repair does not occur, cells will die immediately (cytocidal) or when they attempt to divide (cytostatic). -Cell Cycle Phase-Nonspecific Agents -LEUKERAN (chlorambucil) is indicated in the treatment of chronic lymphatic (lymphocytic) leukemia, malignant lymphomas including lymphosarcoma, giant follicular lymphoma, and Hodgkin's disease. -It is not curative in any of these disorders but may produce clinically useful palliation.

Doxazosin (Cardura)

-Alpha1Adrenergic Blockers -Block α1-adrenergic effects, producing peripheral vasodilation (decreases SVR and BP). Beneficial effects on lipid profile. -Reduced resistance to the outflow of urine in benign prostatic hyperplasia. Taking drug at bedtime reduces risks associated with orthostatic hypotension.

Clonidine (Catapres)

-Alpha2Adrenergic Antagonists -Centrally acting alpha2 receptor agonist -Hypertension -used primarily for its ability to decrease blood pressure. -It is also useful in the management of opioid withdrawal. -It has a better safety profile than the other centrally acting adrenergics and has the advantage of being available in several dosage formulations, including both topical and oral preparations. -When the patch dosage form is used, it is important to remove the old patch before applying a new one. -Clonidine must not be discontinued abruptly, as this will lead to severe rebound hypertension. -Its use is contraindicated in patients who have shown hypersensitivity reactions to it. Recommended dosages are given in the table on this page.

Methyldopa (Aldomet)

-Alpha2Adrenergic Antagonists -Methyldopa is commonly used to treat hypertension in pregnancy. -However, these drugs are not typically prescribed as first-line antihypertensive drugs, because their use is associated with a high incidence of unwanted adverse effects such as orthostatic hypotension, fatigue, and dizziness. -They may be used as adjunct drugs in the treatment of hypertension after other drugs have failed or may be used in conjunction with other antihypertensives such as diuretics.

Losartan (Cozaar)

-Angiotensin II Receptor Blockers (ARBs) -Losartan (Cozaar) is beneficial in patients with hypertension and heart failure. -The use of losartan is contraindicated in patients who are hypersensitive to any component of this product. -It is to be used with caution in patients with renal or hepatic dysfunction and in patients with renal artery stenosis. -Breastfeeding women must not take losartan, because it can cause serious adverse effects on the nursing infant. -Recommended dosages are given in the table on the previous page.

Lisinopril(Zestril)

-Angiotension Converting Enzyme (ACE)

Ramipril(Altace)

-Angiotension Converting Enzyme (ACE)

Enalapril(Vasotec)

-Angiotension Converting Enzyme (ACE) -Aspirin and NSAIDs may reduce drug effectiveness. -Addition of diuretic enhances drug effect. Should not be used with potassium-sparing diuretics. -Can cause increase in serum creatinine. Inhibit breakdown of bradykinin, which may cause a dry, hacking cough that can occur at any point during treatment, even years later. Dilate venules and arterioles • Improve renal blood flow • Decrease fluid volume • Relieve symptoms of heart failure • Promote reverse remodeling • Decrease morbidity and mortality

Captopril (Capoten)

-Angiotension Converting Enzyme (ACE) -Captopril may be given orally for hypertensive crisis -Dilate venules and arterioles • Improve renal blood flow • Decrease fluid volume • Relieve symptoms of heart failure • Promote reverse remodeling • Decrease morbidity and mortality

Benazepril(Lotensin)

-Angiotension Converting Enzyme (ACE) -Dilate venules and arterioles • Improve renal blood flow • Decrease fluid volume • Relieve symptoms of heart failure • Promote reverse remodeling • Decrease morbidity and mortality

Fosinopril(Monopril)

-Angiotension Converting Enzyme (ACE) -control hypertension by decreasing peripheral arterial resistance and pulmonary capillary wedge pressure -improves cardiac output and increases exercise tolerance -first dose may cause syncope due to excessive hypotension -watch for dizziness, hypotension, nausea, vomiting and cough

Argatroban (Argatroban injection)

-Anticoagulant -indicated for treatment of HIT -side effects: Bleeding, dizziness, shortness of breath, fever, urticaria

Procainamide (Pronestyl)

-Antidysrhythmics -Sodium channel blockers block sodium, slowing the impulse in the atria, ventricles, and nodal and Purkinje systems (Quinidine, Procainamide). -treatment for PVCs -IV treatment for ventricular tachycardia -Significant adverse effects include ventricular dysrhythmias and blood disorders. It can cause a systemic lupus erythematosus-like syndrome, which occurs in about 30% of patients on long-term therapy. -It can also cause gastrointestinal effects such as nausea, vomiting, and diarrhea. Other adverse effects include fever, leukopenia, maculopapular rash, flushing, and ttorsades de pointes resulting from prolongation of the QT interval.

Atenolol(Tenormin)

-Atenolol (Tenormin) is a cardioselective beta blocker that is commonly used to prevent future heart attacks in patients who have had one. -It is also used in the treatment of hypertension and angina and in the management of thyrotoxicosis to help block the symptoms of excessive thyroid activity. -Atenolol is available for oral use. Recommended dosages are given in the table on the next page.

Cholestyramine (Questran)

-Bile-Acid Sequestrants -Cholestyramine (Questran) is a prescription-only drug that is contraindicated in patients with a known hypersensitivity to it and in those who have complete biliary obstruction or PKU. -It may interfere with the distribution of proper amounts of fat-soluble vitamins to the fetus or nursing infant of a pregnant or nursing woman taking the drug. -Cholestyramine is now being used for its constipating effect, often given as needed for loose bowel movements. -Cholestyramine is available as a dry powder and poses a choking hazard if not diluted before administering. -All drugs must be taken at least 1 hour before or 4 to 6 hours after the administration of bile acid sequestrants. In addition, high doses of a bile acid sequestrant decrease the absorption of fat-soluble vitamins (A, D, E, and K). -The adverse effects of colestipol, cholestyramine, and colesevelam are similar; however, colesevelam is reported to have fewer gastrointestinal adverse effects and drug interactions. Constipation is a common problem and may be accompanied by heartburn, nausea, belching, and bloating. -Bile acid sequestrants may be used as primary or adjunct drug therapy in the management of type II hyperlipoproteinemia. A common strategy is to use them along with statins for an additive drug effect in reducing LDL cholesterol levels

Ditiazem (Cardizem)

-Cardizem® (diltiazem hydrochloride) is a calcium ion cellular influx inhibitor (slow channel blocker or calcium antagonist) -The therapeutic benefits achieved with Cardizem are believed to be related to its ability to inhibit the influx of calcium ions during membrane depolarization of cardiac and vascular smooth muscle -Cardizem is used to treat hypertension (high blood pressure). It may be used alone or in combination with other high blood pressure medications. -Grapefruit and grapefruit juice may interact with diltiazem and lead to unwanted side effects. Discuss the use of grapefruit products with your doctor. -warning-Cardiac Conduction, Congestive Heart Failure, Hypotension, Acute Hepatic Injury

Carvedilol (Coreg)

-Carvedilol (Coreg) has many effects, including acting as a nonselective beta blocker, an alpha1 blocker, a calcium channel blocker, and possibly an antioxidant. -It is used primarily in the treatment of heart failure but is also beneficial for hypertension and angina. -It has been shown to slow the progression of heart failure and to decrease the frequency of hospitalization in patients with mild to moderate (class II or III) heart failure. -Carvedilol is most commonly added to digoxin, furosemide, and angiotensin-converting enzyme inhibitors when used to treat heart failure. -Carvedilol is available as immediate release and controlled-release formulations.

Ezetimibe (Zetia)

-Cholesterol Absorption Inhibitor -drug therapy for CAD -Func. class.: ​Antilipemic -Action: Inhibits absorption of cholesterol by the small intestine -Therapeutic outcome: Decreased cholesterol levels -Uses: Hypercholesterolemia, homozygous familial hypercholesterolemia (HoFH), homozygous sitosterolemia Contraindications: -Hypersensitivity, severe hepatic disease -Precautions: Pregnancy C, breastfeeding, children, hepatic disease -Dosage and routes Adult: PO 10 mg/day; may be given with HMG-CoA reductase inhibitor at same time; may be given with bile acid sequestrant; give ezetimibe 2 hr before or 4 hr after the bile acid sequestrant -Available forms: Tabs 10 mg Implementation: • -Give without regard to meals Adverse effects CNS: Fatigue, dizziness, headache GI: Diarrhea, abdominal pain Misc: Chest pain MS: Myalgias, arthralgias, back pain, myopathy, rhabdomyolysis Resp: Pharyngitis, sinusitis, cough, URI Pharmacokinetics AbsorptionUnknownDistributionUnknownMetabolismSmall intestine, liverExcretionUrine (11%), feces (78%)Half-lifeUnknown Pharmacodynamics Unknown Interactions Individual drugs Cholestyramine: decreased ezetimibe action CycloSPORINE: increased action of ezetimibe Drug classifications Antacids: decreased action of ezetimibe Fibric acid derivatives: increased ezetimibe action Drug/lab test Increase: LFTs Nursing considerations Assessment •Hypercholesterolemia: obtain diet history; monitor fat content, lipid levels (triglycerides, LDL, HDL, total cholesterol), LFTs baseline and periodically during treatment •Myopathy/rhabdomyolysis: monitor for increased CPK; myalgia, muscle cramps, musculoskeletal pain, lethargy, fatigue, fever; more common when combined with statins Patient/family education • Teach patient that compliance is needed • Advise that risk factors should be decreased: high-fat diet, smoking, alcohol consumption, absence of exercise 414 • Advise patient to notify prescriber if pregnancy is suspected or planned or if breastfeeding • Advise patient to notify prescriber if unexplained weakness, or muscle pain is present • Teach patient to notify prescriber of dietary/herbal supplements Evaluation Positive therapeutic outcome • Decreased cholesterol

Epinephrine (Adrenaline)

-Classification: Adrenergic agonist, catecholamine -Action: Vasoconstriction, increases heart rate and blood pressure, bronchodilator, *treatment of choice for anaphylactic reactions. -Uses: Bronchodilation in clients with acute asthma; treatment of hypersensitivity, anaphylactic reactions, cardiac arrest; produces mydriasis for opthalmologic procedures

Vasodilators

-Direct-acting vasodilators are useful as antihypertensive drugs because of their ability to directly cause peripheral vasodilation. -This results in a reduction in systemic vascular resistance (SVR). -Vasodilators produce significant hypotension. -Contraindications include known drug allergy and may also include hypotension, cerebral edema, head injury, acute MI, and coronary artery disease. -They may also be contraindicated in cases of heart failure that is secondary to diastolic dysfunction.

Epoetin alfa (Epogen, Procrit)

-Epoetin alfa (Epogen, Procrit) is a biosynthetic form of the natural hormone erythropoietin, which is normally secreted by the kidneys in response to a decrease in RBCs. -It promotes the synthesis of erythrocytes (RBCs) by stimulating RBC progenitor 864cells in the bone marrow. -Epoetin alfa is used to treat anemia that is associated with end-stage renal disease, chemotherapy-induced anemia, and for anemia associated with zidovudine therapy -In 2010, the U.S. Food and Drug Administration (FDA) issued a public health advisory regarding the overzealous use of epoetin. It was found that when hemoglobin levels are above 11 g/dL and the drug is continued, patients experienced serious adverse events, including heart attack, stroke, and death. - Use of epoetin and darbepoetin is contraindicated in cases of uncontrolled hypertension and when hemoglobin levels are above 10 g/dL for cancer patients and 11 g/dL for renal patients. - The most frequent adverse effects include hypertension, fever, headache, pruritus, rash, nausea, vomiting, arthralgia, and injection site reaction.

ferric gluconate

-Ferric gluconate (Ferrlecit) is an injectable iron product that is indicated for repletion of total body iron content in patients with iron-deficiency anemia who are undergoing hemodialysis. -Doses higher than 125 mg are associated with increased adverse events, including abdominal pain, dyspnea, cramps, and itching

Fenofibrate (TriCor)

-Fibric Acid Derivatives -Fibric acid inhibitors reduce triglyceride & VLDL lipoproteins. -Decrease hepatic synthesis and secretion of VLDL. Reduce triglycerides by ↓ VLDL ↓ LDL ↓ Triglycerides ↑ HDL -Rashes, mild GI disturbances (e.g., nausea, diarrhea), elevated liver enzymes -May ↑ effects of warfarin (Coumadin) and some antihyperglycemic drugs. -When used in combination with statins, may increase adverse effects of statins, especially myopathy.

Tissue plasminogen activator [(tPA; alteplase (Activase)]

-Fibrinolytics (Thrombolytics) -Activase is indicated for use in acute myocardial infarction (AMI) for the reduction of mortality and reduction of the incidence of heart failure -for stroke -Do not administer Activase to treat acute ischemic stroke in the following situations in which the risk of bleeding is greater than the potential benefit -The most frequent adverse reaction associated with Activase therapy is bleeding.

Streptokinase(Streptase)

-Fibrinolytics (Thrombolytics) -Streptase®, Streptokinase, is a sterile, purified preparation of a bacterial protein elaborated by group C (beta) -hemolytic streptococci -Acute Evolving Transmural Myocardial Infarction: Streptase, Streptokinase, is indicated for use in the management of acute myocardial infarction (AMI) in adults, for the lysis of intracoronary thrombi, the improvement of ventricular function, and the reduction of mortality associated with AMI

Urokinase

-Fibrinolytics (Thrombolytics) -Urokinase is a thrombolytic drug, sometimes called a "clot-busting" drug. It helps your body produce a substance that dissolves unwanted blood clots. -Urokinase increases your risk of bleeding, which can be severe or life-threatening

Recombinant plasminogen activator [rPA; reteplase (Retavase)]

-Fibrinolytics (Thrombolytics) -• Break up fibrin meshwork in clots • Used only in ST-segment-elevation MI when access to a hospital with PCI capability is not available -dissolve thrombi -Retavase® (Reteplase) is indicated for use in the management of acute myocardial infarction (AMI) in adults for the improvement of ventricular function following AMI, the reduction of the incidence of congestive heart failure and the reduction of mortality associated with AMI. -Retavase® (Reteplase) is for intravenous administration only -side effect bleeding

Filgrastim (Neupogen)

-Filgrastim (Neupogen) is a synthetic analogue of human granulocyte colony-stimulating factor and is commonly referred to as G-CSF. -Filgrastim promotes the proliferation, differentiation, and activation of the cells that make granulocytes -Filgrastim is indicated to prevent or treat febrile neutropenia in patients receiving myelosuppressive antineoplastics for nonmyeloid (non-bone marrow) malignancies. -It must be given before a patient develops an infection, but not within 24 hours before or after myelosuppressive chemotherapeutic drugs. -These drugs are usually discontinued when a patient's absolute neutrophil count (ANC) rises above 10,000 cells/mm3.

Adenosine (Adenocard)

-Func. class.: ​Antidysrhythmic—miscellaneous -Chem. class.: ​Endogenous nucleoside -Pregnancy category C -Action: Slows conduction through AV node, can interrupt reentry pathways through AV node, and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (PSVT), decreases cardiac oxygen demand decreasing hypoxia -Therapeutic outcome: Normal sinus rhythm in patients diagnosed with SVT or diagnosis of perfusion defect -Uses: PSVT, as a diagnostic aid to assess myocardial perfusion defects in CAD; Wolff-Parkinson-White (WPW) syndrome -Contraindications: Hypersensitivity, 2nd- or 3rd-degree heart block, AV block, sick sinus syndrome -Precautions: Pregnancy C, breastfeeding, children, geriatric, asthma, atrial flutter, atrial fibrillation, ventricular tachycardia, bronchospastic lung disease, symptomatic bradycardia, bundle branch block, heart transplant, unstable angina, COPD, hypotension, hypovolemia, vascular heart disease, CV disease -Dosage and routes Antidysrhythmic Adult and child >50 kg: IV BOL 6 mg; if conversion to normal sinus rhythm does not occur within 1-2 min, give 12 mg by rapid IV BOL; may repeat 12 mg dose again in 1-2 min Infant and child <50 kg: IV BOL 0.05 mg/kg; if not effective, increase dose by 0.05-0.1 mg/kg q2min to a max of 0.3 mg/kg/dose Neonate: IV BOL: 0.05 mg/kg by rapid IV BOL, may increase by 0.05 mg/kg q2min, max 0.3 mg/kg/dose -Implementation IV, direct (bolus) route • Give IV BOL undiluted; give 6 mg or less by rapid inj; if using an IV line, use port near insertion site, flush with 0.9% NaCl (20 ml), then elevate arm • Store at room temperature; sol should be clear; discard unused product Solution compatibilities: D5LR, D5W, LR, 0.9% NaCl Adverse effects CNS: Light-headedness, dizziness, arm tingling, numbness, headache CV: Chest pain/pressure, atrial tachydysrhythmias, sweating, palpitations, hypotension, facial flushing, AV block, cardiac arrest, ventricular dysrhythmias, atrial fibrillation GI: Nausea, metallic taste Resp: Dyspnea, chest pressure, hyperventilation, bronchospasm (asthmatics) Pharmacokinetics AbsorptionComplete bioavailabilityDistributionErythrocytes, cardiovascular endotheliumMetabolismLiver, converted to inosine and adenosine monophosphateExcretionKidneysHalf-life10 sec Pharmacodynamics OnsetRapidPeakUnknownDuration1-2 min Interactions Individual drugs Caffeine, theophylline: decreased effects of adenosine CarBAMazepine: increased heart block Digoxin, verapamil: increased ventricular fibrillation Dipyridamole: increased effects of adenosine Smoking: increased tachycardia Drug/herb Ginger: increased effect Green tea, guarana: decreased effect Nursing considerations Assessment • Assess cardiopulmonary status: pulse, respiration, ECG intervals (PR, QRS, QT); check for transient dysrhythmias (PVCs, PACs, sinus tachycardia, AV block) • Assess respiratory status: rate, rhythm, lung fields for crackles, watch for respiratory depression; bilateral crackles may occur in CHF patient; if increased respiration, increased pulse occurs, product should be discontinued • Assess CNS effects: dizziness, confusion, paresthesias; product should be discontinued Patient/family education • Tell patient to report facial flushing, dizziness, sweating, palpitations, chest pain Evaluation Positive therapeutic outcome • Normal sinus rhythm -IV adenosine (Adenogard) - 1st drug of choice -Drug Alert Injection site should be as close to the heart as possible (e.g., antecubital area). -Give IV RAPIDLY over 1-2 seconds follow with a rapid 20 mL normal saline flush -Monitor ECG continuously, brief period of asystole common -Observe for flushing, dizziness, chest pain or palpitations

Rosuvastatin(Crestor)

-HMG-CoA Reductase Inhibitors (Statins) -ACTION Lower cholesterol levels by inhibiting the formation of HMG-Co A reductase, which is an enyzme that is required for the liver to synthesize cholesterol. USES •Hypercholesterolemia •Primary and secondary prevention of cardiovascular events •Clients with type 2 diabetes and coronary heart disease CONTRAINDICATIONS •Hepatitis, pregnancy PRECAUTIONS •Liver disease •Excessive alcohol use SIDE EFFECTS •Myopathy—rhabdomyolysis (severe form) •Hepatoxicity—liver injury with increases in serum transaminases NURSING IMPLICATIONS 1.‡Instruct client to report unexplained muscle pain or tenderness. 2.*Monitor liver function studies. 3.‡Inform women of childbearing age about the potential for fetal harm should they become pregnant. 4.*Administer medication in the evening without regard to meals. 5.‡Instruct client about dietary changes to reduce weight and cholesterol

Factor VIII

-Hemophilia A: Caused by mutations in the F8 gene that provides instructions for making coagulation factor VIII -Recessive sex-linked (transmitted by female carriers, displayed almost exclusively in men)

Factor IX

-Hemophilia B: Caused by mutations in the F9 gene that provides instructions for making coagulation factor IX -Recessive sex-linked (transmitted by female carriers, displayed almost exclusively in men)

Hemophilia

-Hemophilia is an X-linked recessive genetic disorder caused by a defective or deficient coagulation factor. The two major types of hemophilia, which can occur in mild to severe forms, are hemophilia A (classic hemophilia, factor VIII deficiency) and hemophilia B (Christmas disease, factor IX deficiency).

Iron (oral: ferrous fumarate, ferric gluconate, ferrous sulfate; parenteral:iron dextran, ferric gluconate, iron sucrose)

-Iron is a mineral that is essential for the proper function of all biologic systems in the body. -It is stored in many sites throughout the body (liver, spleen, and bone marrow). -Deficiency of this mineral is the principal nutritional deficiency resulting in anemia. -Individuals who require the highest amount of iron are women (especially pregnant women) and children, and they are the groups most likely to develop iron-deficiency anemia -Iron is an oxygen carrier in both hemoglobin and myoglobin (oxygen-carrying molecule in muscle tissue) and is critical for tissue respiration -The most common adverse effects associated with oral iron preparations are nausea, vomiting, diarrhea, constipation, stomach cramps, and stomach pain. Excess iron intake can lead to accumulation and iron toxicity. -A serum iron concentration of more than 300 mcg/dL places the patient at serious risk for toxicity. In patients with severe symptoms of iron intoxication, such as coma, shock, or seizures, chelation therapy with deferoxamine is initiated -The absorption of iron can be enhanced when it is given with ascorbic acid and decreased when it is given with antacids and calcium

iron sucrose

-Iron sucrose (Venofer) is another injectable iron product indicated for the treatment of iron-deficiency anemia in patients with chronic renal disease. It is also used for patients without kidney disease -hypotension is adverse effect

Labetatol (Trandate)

-Labetalol (Normodyne) is unusual in that it can block both alpha- and beta-adrenergic receptors. -It is used in the treatment of severe hypertension and hypertensive emergencies to quickly lower the blood pressure before permanent damage is done. -Labetalol is available for oral and injectable use. -Recommended dosages are given in the table above

Lidocaine hydrochloride (Xylocaine)

-Lidocaine (Xylocaine) is the prototypical Ib drug. It is effective for the treatment of ventricular dysrhythmias, but it can only be administered intravenously because it has an extensive first-pass effect (i.e., when it is taken orally, the liver metabolizes most of it to inactive metabolites). -Because of its extensive hepatic metabolism, dosage reduction by 50% is recommended for patients with liver failure or cirrhosis. -Dosage reductions may also be necessary in patients with renal impairment because of extensive excretion of the drug and its metabolites by the kidney. -Lidocaine exerts its effects on the conduction system of the heart by making it difficult for the ventricles to develop a dysrhythmia. This action is known as raising the ventricular fibrillation threshold. -It occurs by decreasing the sensitivity of the cardiac cell membrane to impulses and decreasing the cell's ability to depolarize on its own (decreasing automaticity). Many of these effects are accomplished by blocking the fast sodium channels. -Significant adverse effects include CNS toxic effects such as twitching, convulsions, and confusion; respiratory depression or arrest; and the cardiovascular effects of hypotension, bradycardia, and dysrhythmias. -Use of the drug is contraindicated in patients who are hypersensitive to it, who have severe SA or AV intraventricular block, or who have Stokes-Adams or Wolff-Parkinson-White syndrome. -Lidocaine is available only in parenteral form for intramuscular or intravenous administration. -Lidocaine is commonly used as a local anesthetic; a transdermal form is also available for analgesia

Metoprolol (Lopressor)

-Metoprolol (Lopressor) is the most commonly used beta1 blocker. -Recent studies of metoprolol have shown increased survival in patients given the drug after they have experienced an MI. -Metoprolol is available for oral and injectable use. -When metoprolol is given IV, it is considered a high-alert drug and the patient should be monitored. -Recommended dosages are given in the table above.

Morphine Sulfate

-Opiod analgesics -Morphine Sulfate CLASSIFICATION Analgesic, opioid agonist ACTION Interacts at a specific receptor-binding site. Agonist activity at the receptor site can result in analgesia, euphoria, depression, hallucinations, miosis, and sedation. Alters pain at the spinal cord and higher levels in the CNS. USES •Relieves mild-to-severe pain. •Decreases anxiety, therefore decreases myocardial oxygen demands with pain from a myocardial infarction. CONTRAINDICATIONS •Hypersensitivity •Intracranial pressure and suspected head injuries; may mask the development of increased intracranial pressure (IICP). •Hepatic and renal dysfunction PRECAUTIONS •Seizures, asthma, and severe respiratory depression SIDE EFFECTS •†Respiratory depression •Urinary retention, **confusion •**Constipation, nausea and vomiting •**Orthostatic hypotension •Tolerance and physical dependency with long-term use •Toxicity: coma, respiratory depression, and pinpoint pupils †Serious/life-threatening implications **Most frequent side effects NURSING IMPLICATIONS 1.Perform strict documentation and inventory assessment of narcotic. 2.*Assess pain and vital signs (especially respirations) before and after the dose; do not administer if respirations are below 12 per minute. 3.Infants and older adults are very sensitive to depression of respirations. 4.Naloxone (Narcan) reverses the effect of morphine. 5.Medication of choice for patient-controlled analgesic (PCA). -is respirations are less than 12 per min call doc

Oprelvekin (Neumega)

-Oprelvekin (Neumega) is both a hematopoietic drug and one of the interleukins. -However, its function is similar to that of the colony-stimulating factors (filgrastim and sargramostim) in that it enhances synthesis of a specific blood component—in this case, the platelets. -Oprelvekin is indicated for the prevention of chemotherapy-induced severe thrombocytopenia and avoidance of the need for platelet transfusions. -Its use is contraindicated in cases of known drug allergy. -It is available for injection only.

Mexiletine (Mexitil)

-Oral Antiarrhythmic -MEXITIL (mexiletine hydrochloride, USP) is indicated for the treatment of documented ventricular arrhythmias, such as sustained ventricular tachycardia, that, in the judgement of the physician, are life-threatening -side effects-palpations, chest pain, increased ventricular arrhythmia, PVCs, N/V/D,dizziness, tremor, nervousness, coordination difficulties, changes in sleep habits, weakness, fatigue, tinnitus, headache, blurred vision, dyspnea, rash, non-specific edema

Digitalis glycoside [digoxin (Lanoxin)]

-Positive Inotropes -Digoxin (Lanoxin) is indicated for the treatment of heart failure and atrial fibrillation and flutter. -Digoxin use is contraindicated in patients who have shown a hypersensitivity to it and in those with ventricular tachycardia and fibrillation. -Normal therapeutic drug levels of digoxin are between 0.5 and 2 ng/mL. -However, levels higher than 2 ng/mL are used for the treatment of atrial fibrillation. -Digoxin is available in oral and injectable forms. Because of digoxin's fairly long duration of action and half-life, a loading, or "digitalizing," dose is often given to bring serum levels of the drug up to a desirable therapeutic level more quickly. -Digoxin has a low therapeutic index (see Chapter 2). Digoxin levels are monitored when the patient first starts taking the drug. However, once the drug reaches steady state, monitoring is usually necessary only if there is suspicion of toxicity, noncompliance, or deteriorating renal function. Normal therapeutic levels for digoxin are 0.5 to 2 ng/mL. Low potassium or magnesium levels may increase the potential for digoxin toxicity. Therefore, frequent monitoring of serum electrolytes is also important. A decrease in renal function is a common cause of digoxin toxicity, because digoxin is excreted almost exclusively via the kidneys. Signs and symptoms of digoxin toxicity include bradycardia, headache, dizziness, confusion, nausea, and visual disturbances (blurred vision or yellow vision). With toxicity, ECG findings may include heart block, atrial tachycardia with block, or ventricular dysrhythmias. Predisposing factors to digoxin toxicity are listed in -The beneficial effect of digoxin is thought to be an increase in myocardial contractility—known as a positive inotropic effect. -Cardiovascular Bradycardia or tachycardia; hypotension -Central nervous Headache, fatigue, confusion, convulsions -Eye;Colored vision (i.e., green, yellow, or purple), halo vision -Gastrointestinal Anorexia, nausea, vomiting, diarrhea

B adrenergic agonists [dopamine (Intropin); dobutamine (Dobutrex)]

-Positive Inotropes -Dobutamine (Dobutrex) is a beta1-selective vasoactive adrenergic drug that is structurally similar to the naturally occurring catecholamine dopamine. Through stimulation of the beta1 receptors on heart muscle (myocardium), it increases cardiac output by increasing contractility (positive inotropy), which increases the stroke volume, especially in patients with heart failure. Dobutamine is available only as an intravenous drug and is given by continuous infusion.

Phosphodiesterase inhibitors [inamrinone (Inocor), milrinone (Primacor)]

-Positive Inotropes -Phosphodiesterae inhibitor -for heart failure -Milrinone (Primacor) is the only available PDI. Milrinone is also referred to as an inodilator because it exerts both a positive inotropic effect and a vasodilatory effect. Milrinone is contraindicated in cases of known drug allergy. -Adverse effects include cardiac dysrhythmias, headache, hypokalemia, tremor, thrombocytopenia, and elevated liver enzyme levels. -Interacting drugs include diuretics (additive hypotensive effects) and digoxin (additive inotropic effects). -Milrinone is available only in injectable form. -Recommended dosages are given in the table on the previous page.

Isosorbide dinitrate(Isordil)

-Promote peripheral vasodilation, decreasing preload and afterload • Promote coronary artery vasodilation • May prevent or control coronary vasospasm

Propranolol(Inderal)

-Propranolol (Inderal) is the prototypical nonselective beta1- and beta2-blocking drug. It was one of the very first beta 316blockers. -Lengthy experience has revealed many uses for it. -In addition to the indications mentioned for metoprolol, propranolol has been used for the treatment of tachydysrhythmias associated with cardiac glycoside intoxication and for the treatment of hypertrophic subaortic stenosis, pheochromocytoma, thyrotoxicosis, migraine headache, essential tremor, and many other conditions. -The same contraindications that apply to the cardioselective beta blockers discussed earlier hold for propranolol as well. -In addition, its use is contraindicated in patients with bronchial asthma. -Propranolol is available for oral and injectable use.

Quinidine (Quinidex)

-Quinidine (Quinidex) has both a direct action on the electrical activity of the heart and an indirect (anticholinergic) effect. -Significant adverse effects of the drug include cardiac asystole and ventricular ectopic beats. -Quinidine can cause cinchonism. -Symptoms of mild cinchonism include tinnitus, loss of hearing, slight blurring of vision, and gastrointestinal upset. -Contraindications to the use of the drug include hypersensitivity, thrombocytopenic purpura resulting from previous therapy, AV block, intraventricular conduction defects, and torsades de pointes. -Quinidine is available in both oral and parenteral (injectable) forms and in three different salt forms. -antidysrythmIc

Sargramostim (Leukine)

-Sargramostim (Leukine) is a synthetic analogue of human granulocyte-macrophage colony-stimulating factor and is commonly referred to as GM-CSF -It stimulates the proliferation, differentiation, and activation of the cells in the bone marrow that eventually become granulocytes, monocytes, and macrophages. -Sargramostim is indicated for promoting bone marrow recovery after autologous (own marrow) or allogenic (donor marrow) bone marrow transplantation in patients with various types of leukemia and lymphoma

Sotalol (Betapace)

-Sotalol (Betapace) is a nonselective beta blocker that has very potent antidysrhythmic properties. -It is commonly used for the management of difficult-to-treat dysrhythmias. -Often these dysrhythmias are life-threatening ventricular dysrhythmias such as sustained ventricular tachycardia. -It has properties characteristic of both a class II and class III antidysrhythmic drug -Because it is a nonselective beta blocker, it causes some of the unwanted adverse effects typical of these drugs (e.g., hypotension). -Sotalol is available only for oral use.

docusate sodium [Colace]

-Stool softeners (e.g., docusate sodium [Colace]) are given to facilitate and promote the comfort of bowel evacuation. -This prevents straining and resultant vagal stimulation from the Valsalva maneuver -Hyperosmotic laxative -Docusate salts (calcium and sodium) (Colace) are stool-softening emollient laxatives that facilitate the passage of water and lipids (fats) into the fecal mass, which softens the stool. -These drugs are used to treat constipation, to soften fecal impactions, and to prevent opioid-induced constipation. -Docusate does not cause patients to defecate; it simply softens the stool to ease its passage. In addition to the docusate salt formulations, combination products are also available. -Docusate use is contraindicated in patients with intestinal obstruction, fecal impaction, or nausea and vomiting.

Digitalis glycoside (Digoxin)

-The digitalis glycosides are potent cardiovascular drugs with a low therapeutic index and a high incidence of iatrogenic complications. -Digoxin is the most commonly used preparation. Common indications include rate control in atrial fibrillation, as well as the treatment of other atrial tachyarrhythmias, and low-output congestive heart failure. -Digitalis is contraindicated in idiopathic hypertrophic subaortic stenosis (unless atrial fibrillation is present) and in some patients with Wolff-Parkinson-White syndrome. - Supraventricular dysrhythmias • Atrial fibrillation -adverse reactions: Bradycardia, Dysrhythmias, Anorexia, nausea, vomiting, diarrhea, visual disturbances Monitor pulse rate and rhythm. -Check apical pulse for one full minute before administering; hold if blood pressure is less than 60 bpm and notify health care provider. • Instruct client to report signs of toxicity. • Hypokalemia increases the risk for toxicity. • Causes hypercalcemia.

Hydrochlorothiazide (Hydrodiuril)

-Thiazide diuretic -Inhibit NaCl reabsorption in the distal convoluted tubule. Increase excretion of Na+ and Cl−. Initial decrease in ECF. Sustained decrease in SVR. Lower BP moderately in 2-4 wk -Monitor for orthostatic hypotension, hypokalemia, and alkalosis. -Thiazides may potentiate cardiotoxicity of digoxin by producing hypokalemia. -Dietary sodium restriction reduces the risk of hypokalemia. NSAIDs can decrease diuretic and antihypertensive effect of thiazide diuretics and potentially cause renal impairment. -Advise patient to supplement with potassium-rich foods.

Valsartan (Diovan)

-Valsartan (Diovan) is a commonly used ARB. Like all ARBs, it is a pregnancy category D drug. -Valsartan shares many of the same adverse effects as lisinopril, profiled earlier. -The ARBs are not as likely to cause the cough associated with the ACE inhibitors, nor are they as likely to cause hyperkalemia. -interacts with NSAIDs, lithium, rifampin, potassium supplements and potassium sparing diuretics

Hydralazine (Apresoline)

-Vasodilator -Hydralazine (Apresoline) is taken orally to treat routine cases of essential hypertension. -It can also be given intravenously and is useful for patients who cannot tolerate oral therapy in the hospital or for hypertensive emergencies. -Contraindications include drug allergy, coronary artery disease, and mitral valve dysfunction. -drug combination is known as BiDil, and it is specifically indicated as an adjunct for treatment of heart failure in African-American patients. -Hydralazine toxicity or overdose produces hypotension, tachycardia, headache, and generalized skin flushing. -Treatment is supportive and symptomatic and includes the administration of intravenous fluids, digitalization if needed, and the administration of beta blockers for the control of tachycardia

warfarin (Coumadin)

-anticoagulant -Antagonist: vitamin K -Laboratory: PT determines efficacy -Keep 1.5 to 2.5 times normal control -INR (international normalized ratio): desirable therapeutic level usually 2:3 (reflects how long it takes a blood sample to clot) -observe for bleeding -avoid alcohol -Maintain pressure on venipuncture sites to minimize hematoma formation. 8. Notify physician of any unusual bleeding. a. Abnormal vaginal bleeding b. Nosebleeds c. Melena d. Hematuria e. Gums f. Hemoptysis 9. Advise client to use soft toothbrush, floss with waxed floss. 10. Advise client to wear medical alert symbol. 11. Advise client to avoid alcoholic beverages. 12. Advise client to avoid safety razors if taking warfarin (Coumadin). 113 13. Advise client to avoid aspirin and aspirin products and NSAIDs.

Heparin

-anticoagulant -Heparin prevents conversion of fibrinogen to fibrin and prothrombin to thrombin, thereby inhibiting clot formation. -Because the clotting mechanism is prolonged, do not cause tissue trauma, which may lead to bleeding when giving heparin subcutaneously. -Do not massage area or aspirate; give in the abdomen between the pelvic bones, 2 inches from umbilicus; rotate sites. -Antagonist: protamine sulfate Laboratory: PTT or aPTT determines efficacy Keep 1.5 to 2.5 times normal control

Enoxaparin (Lovenox)

-anticoagulant -Prevention and treatment of thromboembolic and ischemic processes in unstable angina and postoperative and post-MI situations -Routine coagulation tests typically not required. -Monitor CBC count at regular intervals. -Do not expel air bubble before administering subcutaneously. -Follow remaining administration guidelines as described above for UH. -Reduced dosage needed in patients with renal impairment. -Use extreme caution in patients with a history of HIT. -Antidote: Protamine neutralizes the effects of LMWH.

Amiodarone hydrochloride (Cordarone)

-antidysrhythmic -• Amiodarone is now one of the first-choice drugs. • Monitor vital signs, ECG. • Instruct client taking amiodarone to wear sunglasses and sunscreens when outside. -• Amiodarone is now one of the first-choice drugs. • Monitor vital signs, ECG. • Instruct client taking amiodarone to wear sunglasses and sunscreens when outside. -Amiodarone has many unwanted adverse effects, and these can be attributed to its chemical properties. Amiodarone is very lipophilic, or fat loving. Therefore, it can penetrate and concentrate in the adipose tissue of any organ in the body. It also has iodine in its chemical structure. One organ that sequesters iodine from the diet is the thyroid gland. As a result, amiodarone can cause either hypothyroidism or hyperthyroidism -Adverse reactions occur in approximately 75% of patients treated with this drug, but the incidence is higher and the severity greater with higher dosages (those exceeding 400 mg/day) and prolonged therapy. One of the most common adverse effects is corneal microdeposits, which may cause visual halos, photophobia, and dry eyes. This occurs in virtually all adults who take the drug for longer than 6 months. Photosensitivity is also very common, reported in 10% to 75% of patients taking amiodarone -The most serious adverse effect is pulmonary toxicity, -Amiodarone has two very significant drug interactions, namely with digoxin and warfarin. It is reported that digoxin levels will increase by 50% and that the INR will increase by 50% in 100% of patients taking these drugs in combination with amiodarone. When amiodarone is started in patients who 404are already taking one of these drugs, the dose of digoxin or warfarin is recommended to be reduced by 50% at the start of amiodarone therapy.

Propranolol hydrochloride (Inderal)

-beta blocker ACTION Blocks sympathetic nervous system catecholamines, resulting in reduced renin and aldosterone release and fluid balance. Vasodilation of arterioles leads to a decrease in pulmonary vascular resistance and blood pressure. USES •Hypertension, antianginal agents in long-term treatment of angina •Dysrhythmias—suppress sinus and atrial tachydysrhythmias CONTRAINDICATIONS •Atrioventricular (AV) block, bradydysrhythmias PRECAUTIONS •Can cause bronchoconstriction; use with caution in clients with diabetes, cerebrovascular insufficiency, renal or hepatic dysfunction. •History of depression, heart failure SIDE EFFECTS •Postural hypotension, †bradycardia, ** drowsiness, depression, †symptoms of congestive heart failure •†Bronchospasm, bronchoconstriction, malaise, **lethargy NURSING IMPLICATIONS 1.*Assess vital signs; monitor closely if given with a calcium channel blocker. 2.‡Report any weakness, dizziness, bradycardia, or fainting. 3.‡Take medication before meals. 4.‡Report any edema or difficulty breathing. 5.*Monitor clients with diabetes; tachycardia (a symptom of hypoglycemia) is often masked because of the beta1 blockade. -for sinus tachycarida -Antidysrhythmics

methyldopa (Aldomet)

-can result in Hemolytic anemia -it is antihypertensive drug

Ascorbic acid (Vitamin C)

-enhances iron absorption

Gemfibrozil (Lopid)

-fibrate -Gemfibrozil (Lopid) -May increase the risk of bleeding in patients taking warfarin (Coumadin). -May increase the effects of antihyperglycemic drugs (e.g., repaglinide [Prandin]). -Decrease hepatic synthesis and secretion of VLDL. Reduce triglycerides by ↓ VLDL ↓ LDL ↓ Triglycerides ↑ HDL -Rashes, mild GI disturbances (e.g., nausea, diarrhea), elevated liver enzymes -May ↑ effects of warfarin (Coumadin) and some antihyperglycemic drugs. -When used in combination with statins, may increase adverse effects of statins, especially myopathy.

Furosemide (Lasix)

-loop diuretic -Inhibit NaCl reabsorption in the ascending limb of the loop of Henle. -Increase excretion of Na+ and Cl−. -More potent diuretic effect than thiazides, but shorter duration of action. -Less effective for hypertension. -Monitor for orthostatic hypotension and electrolyte abnormalities. -Loop diuretics remain effective despite renal insufficiency. --Diuretic effect of drug increases at higher doses. -Furosemide use is contraindicated in patients who have shown hypersensitivity to it or to the sulfonamides (see previous discussion regarding sulfonamide allergy) and in patients with anuria, hypovolemia, or electrolyte depletion.

Cobalamin (Vitamin B12)

-role in erythropoiesis- RBC maturation -food sources- red meats, liver, eggs, enriched grain products -deficiency causes megaloblastic anemias -adverse effects- heart failure, peripheral, vascular thrombosis, pulmonary edema, flushing, optic nerve atrophy, diarrhea, itching, rash, pain at injection site, hypokalemia -The most common manifestation of untreated cyanocobalamin deficiency is pernicious anemia

Folic Acid (Folvite, Vitamin B9)

-role in erythropoiesis- RBC maturation -food sources- green leafy vegetables, liver, meat, fish, legumes, whole grains -anemia results from folic acid deficiency - Also a cause of megaloblastic anemia -Folic acid is required for DNA synthesis RBC formation and maturation -Common causes Poor nutrition --Malabsorption syndromes --Drugs --Alcohol abuse and anorexia ---Lost during hemodialysis -Clinical manifestations are similar to those of cobalamin deficiency -Insidious onset -Absence of neurologic problems -Treated by replacement therapy -Encourage patient to eat foods with large amounts of folic acid -Folic acid is a water-soluble B-complex vitamin that is used primarily in the treatment and prevention of folic acid deficiency and anemias caused by folic acid deficiency. Folic acid is available as an OTC medication in multivitamin preparations and by prescription as a single drug. It is contraindicated in patients with anemias other than megaloblastic or macrocytic anemia. These conditions representing contraindications include vitamin B12 deficiency anemia and uncorrected pernicious anemia. Folic acid is available for both oral and injectable use.

Pyridoxine (Vitamin B6)

-role in erythropoiesis- hemoglobin synthesis -food sources- meats, wheat germ, legumes, potatoes, cornmeal, banana

Angiotensin II Receptor Blockers (ARBs)

-the ARBs block the binding of AII to type 1 AII receptors. -The ACE inhibitors such as enalapril block conversion of AI to AII. -For comparison, recall that ACE inhibitors block the breakdown of bradykinins and substance P, which accumulate and may cause adverse effects such as cough but might also contribute to the drugs' antihypertensive, cardiac, and nephroprotective effects. -Bradykinins are potent vasodilators and help to reduce blood pressure by dilating arteries and decreasing SVR. - ARBs affect primarily vascular smooth muscle and the adrenal gland. -The therapeutic effects of ARBs are related to their potent vasodilating properties. -They are excellent antihypertensives and adjunctive drugs for the treatment of heart failure. -They may be used alone or in combination with other drugs such as diuretics in the treatment of hypertension or heart failure. -The beneficial hemodynamic effect of ARBs is their ability to decrease SVR -Contraindications to the use of ARBs are known drug allergy, pregnancy, and lactation. -They need to be used cautiously in older adults and in patients with renal dysfunction. -As with other antihypertensives, blood pressure and apical pulse rate need to be assessed before and during drug therapy. -The most common adverse effects of ARBs are chest pain, fatigue, hypoglycemia, diarrhea, urinary tract infection, anemia, and weakness. Hyperkalemia and cough less common

Sodium nitroprusside (Nipride)

-vasodilator -Sodium nitroprusside (Nitropress) is used in the intensive care setting for severe hypertensive emergencies and is titrated to effect by intravenous infusion. -Its use is contraindicated in patients with a known hypersensitivity to the drug, severe heart failure, and known inadequate cerebral perfusion (especially during neurosurgical procedures)

Bumetanide (Bumex)

ACTION Loop diuretics inhibit sodium (Na) and chloride (Cl) reabsorption through direct action primarily in the ascending loop of Henle but also in the proximal and distal tubules. Thiazide diuretics act primarily on the distal tubules, inhibiting Na and Cl reabsorption. USES •Treat edema that involves fluid volume excess resulting from a number of disorders of the heart, liver, or kidney •Hypertension CONTRAINDICATIONS •Pregnancy, breastfeeding •Severe adrenocortical impairment, anuria, progressive oliguria PRECAUTIONS •Fluid and electrolyte depletion, gout •Clients taking digitalis, lithium, nonsteroidal antiinflammatory drugs (NSAIDs), and other antihypertensive medications SIDE EFFECTS •**Dehydration, hyponatremia, hypochloremia, hypokalemia •**Unusual tiredness, weakness, dizziness •Irregular heart beat, weak pulse, orthostatic hypotension •Tinnitus, hyperglycemia, hyperuricemia, hearing loss (Lasix) **Most frequent side effects NURSING IMPLICATIONS 1.*Monitor for adequate intake and output and potassium loss. 2.*Monitor client's weight and vital signs. 3.*Monitor for signs and symptoms of hearing loss, which may last from 1 to 24 hours. 4.‡Teach client to take medication early in the day to decrease nocturia. 5.‡Teach client to report any hearing loss or signs of gout.

Diuretics

ACTION Loop diuretics inhibit sodium (Na) and chloride (Cl) reabsorption through direct action primarily in the ascending loop of Henle but also in the proximal and distal tubules. Thiazide diuretics act primarily on the distal tubules, inhibiting Na and Cl reabsorption. USES •Treat edema that involves fluid volume excess resulting from a number of disorders of the heart, liver, or kidney •Hypertension CONTRAINDICATIONS •Pregnancy, breastfeeding •Severe adrenocortical impairment, anuria, progressive oliguria PRECAUTIONS •Fluid and electrolyte depletion, gout •Clients taking digitalis, lithium, nonsteroidal antiinflammatory drugs (NSAIDs), and other antihypertensive medications SIDE EFFECTS •**Dehydration, hyponatremia, hypochloremia, hypokalemia •**Unusual tiredness, weakness, dizziness •Irregular heart beat, weak pulse, orthostatic hypotension •Tinnitus, hyperglycemia, hyperuricemia, hearing loss (Lasix) **Most frequent side effects NURSING IMPLICATIONS 1.*Monitor for adequate intake and output and potassium loss. 2.*Monitor client's weight and vital signs. 3.*Monitor for signs and symptoms of hearing loss, which may last from 1 to 24 hours. 4.‡Teach client to take medication early in the day to decrease nocturia. 5.‡Teach client to report any hearing loss or signs of gout.

Alpha1Adrenergic Blockers

ACTION Stimulate central alpha receptors, which decreases sympathetic outflow from the central nervous system, causing a decrease in peripheral vascular resistance and a slight decrease in cardiac output. USES •Mild-to-moderate hypertension CONTRAINDICATIONS •Hypersensitivity to drug and sulfites PRECAUTIONS •Clients with liver disease, blood dyscrasias, and pheochromocytoma SIDE EFFECTS •**Orthostatic hypotension, tachycardia, **vertigo •Sexual dysfunction, nasal congestion, dry mouth NURSING IMPLICATIONS 1.*Watch for orthostatic hypotension, which is intensified with prolonged standing, hot baths or showers, hot weather, alcohol use, and strenuous exercise. 2.Client should consume no more than four cups of caffeinated coffee, tea, or cola per day. 3.‡Client should take at bedtime to avoid drowsiness during the day. 4.*Discontinue slowly to avoid rebound hypertension. 5.‡Teach client about first dose effect of severe orthostatic hypotension and to avoid hazardous activities and driving for 12 to 24 hours after initial dose. To decrease risk instruct client to take first dose at bedtime.

Atropine

ATROPINE Classification: Anticholinergic, antidysrhythmic -Action: Selectively blocks cholinergic receptors; increases heart rate in bradycardia; decreases secretions. -Uses: Symptomatic bradycardia, **decreases respiratory secretions, reverses effects of anticholinesterase medications -Atropine is also used as an antidote for anticholinesterase inhibitor toxicity or poisoning. It is also used preoperatively to reduce salivation and GI secretions, as is glycopyrrolate

aspirin

Acetylsalicylic Acid (Aspirin, ASA) CLASSIFICATION •Analgesic, antipyretic, antiplatelet; NSAID ACTION Inhibits formation of prostaglandins involved in the production of inflammation, pain, and fever. Inhibits platelet aggregation. USES •Relieves low-to-moderate pain. •Decreases inflammation in conditions: systemic lupus erythematosus, rheumatoid arthritis, osteoarthritis, bursitis, and tendonitis. •Prophylaxis against or reduction of the recurrence of transient ischemic attack and myocardial infarction. CONTRAINDICATIONS AND PRECAUTIONS •Hypersensitivity to salicylates •Clients with diagnosed bleeding disorders •Do not use during pregnancy •History of gastrointestinal (GI) ulceration, bleeding problems •†Recent history of viral infection (influenza and chickenpox) in children has been associated with Reyes syndrome. SIDE EFFECTS •Decreases platelet aggregation; **increases bleeding potential •**Epigastric distress, heartburn, and nausea •Aspirin overdose or toxicity—**tinnitus, generalized pruritus, headache that may progress to further deterioration with respiratory changes, hyperthermia, sweating, and dehydration with electrolyte imbalance NURSING IMPLICATIONS 1.‡Give with milk or full glass of water to decrease gastric irritation. 2.‡Teach safety measures to parents regarding medications at home. 3.*The potential for toxicity is high in older adults and children. 4.‡Teach to avoid concurrent use of alcohol to decrease GI irritation. 5.‡Client should not take aspirin for at least 1 week before surgery. 6.*Evaluate client to determine purpose of medication—pain, inflammation, or antiplatelet action. -anti-inflammatory, anti-pain, anti-pyretic, anti-platelet aggregation

Prazosin (Minipress)

Alpha1Adrenergic Blockers

Terazosin (Hytrin)

Alpha1Adrenergic Blockers -Alpha1Adrenergic Blockers -Block α1-adrenergic effects, producing peripheral vasodilation (decreases SVR and BP). Beneficial effects on lipid profile. -Reduced resistance to the outflow of urine in benign prostatic hyperplasia. Taking drug at bedtime reduces risks associated with orthostatic hypotension.

Angiotensin Converting Enzyme (ACE) Inhibitors

Angiotensin Converting Enzyme (ACE) Inhibitors ACTION Suppress formation of angiotensin II from the renin-angiotensin-aldosterone system, reduce peripheral resistance, and improve cardiac output. -Inhibit ACE, reduce conversion of angiotensin I to angiotensin II (A-II). -Inhibit A-II-mediated vasoconstriction. USES •Hypertension •Heart failure CONTRAINDICATIONS •History of angioedema •Second and third trimesters of pregnancy •Renal artery stenosis PRECAUTIONS •Renal impairment, collagen vascular disease •Hypovolemia, salt depletion SIDE EFFECTS •Headache, dizziness, **postural hypotension •Rash, †angioedema •**Altered sense of taste •**Nagging, nonproductive cough NURSING IMPLICATIONS 1.Regularly *monitor blood pressure, especially for 2 hours after the first dose, because severe first-dose hypotension often develops. 2.‡Teach client to rise slowly from a lying to a sitting position to reduce postural hypotensive effects. 3.*Before administration, assess the client for history or presence of renal impairment. 4.*Administer on an empty stomach for best absorption. 5.‡Teach client to notify health care provider if cough develops. 6.‡Teach client to avoid potassium supplements or potassium containing salt substitutes.

Atorvastatin(Lipitor)

Atorvastatin (Lipitor) has become one of the most commonly used drugs in this class of cholesterol-lowering drugs. -It is used to lower total and LDL cholesterol levels as well as triglyceride levels. -Atorvastatin has also been shown to raise levels of "good" cholesterol, the HDL component. -All statins are dosed once daily, usually with the evening meal or at bedtime. -Bedtime dosing provides peak drug levels in a time frame that correlates better with the natural diurnal (daytime) rhythm of cholesterol production in the body. -It is classified as a pregnancy category X drug.

Nadolol(Corgard)

Beta Blocker

Beta1-adrenergic Blockers

Beta-Adrenergic Antagonists (Beta-Blockers) EXAMPLES Inderal, Tenormin, Lopressor, Corgard ACTION Blocks sympathetic nervous system catecholamines, resulting in reduced renin and aldosterone release and fluid balance. Vasodilation of arterioles leads to a decrease in pulmonary vascular resistance and blood pressure. USES •Hypertension, antianginal agents in long-term treatment of angina •Dysrhythmias—suppress sinus and atrial tachydysrhythmias CONTRAINDICATIONS •Atrioventricular (AV) block, bradydysrhythmias PRECAUTIONS •Can cause bronchoconstriction; use with caution in clients with diabetes, cerebrovascular insufficiency, renal or hepatic dysfunction. •History of depression, heart failure SIDE EFFECTS •Postural hypotension, †bradycardia, ** drowsiness, depression, †symptoms of congestive heart failure (Coughing, SOB, edema, fatigue) •†Bronchospasm, bronchoconstriction, malaise, **lethargy NURSING IMPLICATIONS 1.*Assess vital signs; monitor closely if given with a calcium channel blocker. 2.‡Report any weakness, dizziness, bradycardia, or fainting. 3.‡Take medication before meals. 4.‡Report any edema or difficulty breathing. 5.*Monitor clients with diabetes; tachycardia (a symptom of hypoglycemia) is often masked because of the beta1 blockade -Indications for beta blockers include angina, MI, cardiac dysrhythmias, hypertension, and heart failure. Beta blockers are commonly used in the treatment of angina, or chest pain -Contraindications to the use of beta blockers include known drug allergies and may include uncompensated heart failure, cardiogenic shock, heart block or bradycardia, pregnancy, severe pulmonary disease, and Raynaud's disease. All beta blockers share a black box warning stating that therapy should not be withdrawn abruptly, but should be tapered over 1 to 2 weeks

Hypertensive ABC

CLASSIFICATION Blood pressure is regulated by cardiac output (CO) and peripheral vascular resistance (PVR). Medications that influence either one of these systems lead to blood pressure control. Antihypertensive drugs that influence these systems to lower the blood pressure are angiotensin-converting enzyme (ACE) inhibitors, beta-adrenergic blockers, and calcium channel blockers (CCBs). ACTION •A—ACE inhibitors block the conversion of angiotensin I to angiotensin II, a vasoconstrictor. This block causes vasodilation and therefore decreases PVR, resulting in a decrease in blood pressure. Aldosterone is also blocked, causing a decrease in sodium and water retention. •B—Beta-adrenergic blockers prevent sympathetic stimulation of the heart, thereby reducing heart rate and contractility. •C—CCBs block calcium influx into the beta-receptors, decrease the force of the myocardial contraction, reduce the heart rate, and decrease PVR. USES •Mild-to-moderate essential hypertension •Frequently in combination either as separate drugs or in a combination drug NURSING IMPLICATIONS 1.*Initial drug selection starts with a thiazide diuretic, typically followed by a beta-adrenergic blockers or an ACE inhibitor or CCB. 2.‡Take medication as prescribed; do not stop abruptly. 3.‡Teach client never to double-up on doses if a dose is missed. 4.‡Change positions slowly; watch for postural hypertension. 5.‡Avoid over-the-counter medications. 6.‡Take caution in hot weather, hot showers, hot tub baths, or prolonged sitting or standing because these may aggravate low blood pressure. 7.‡Teach client about multidrug therapy, and not discontinue previous antihypertensive medication when another medication is started.

Calcium Channel Blockers (CCBs)

CLASSIFICATION Calcium channel blockers ACTION Block calcium access to the cells, causing decreased heart contractility and conductivity and leading to a decreased demand for oxygen. USES •Angina, hypertension (nifedipine), and dysrhythmias (verapamil and diltiazem) CONTRAINDICATIONS •Nifedipine: Hypersensitivity •Verapamil: Severe left ventricular dysfunction, decreased blood pressure, cardiogenic shock, or heart block •Diltiazem: Sick sinus syndrome, heart block, decreased blood pressure, acute myocardial infarction, or pulmonary congestion PRECAUTIONS •Renal or hepatic insufficiency •Do not give verapamil or diltiazem with beta blockers SIDE EFFECTS •Decreased blood pressure, **edema of the extremities, headache •Constipation, nausea, skin flushing, †dysrhythmias -bradycardia, may precipitate A-V block, abdominal discomfort NURSING IMPLICATIONS 1.Administer before meals; may be taken with food if needed; *do not crush or allow client to chew sustained-release medication preparations. 2.*Monitor vital signs and watch for low blood pressure. 3.‡Teach about postural hypotension. 4.Check liver and renal function studies. 5.*Weigh client; report any edema or weight gain. 6.‡Teach client to avoid grapefruit. 7.‡Teach client that constipation can be minimized by increasing dietary fiber and fluid.

Spironolactone (Aldactone)

CLASSIFICATION Potassium-sparing diuretic ACTION Has a direct effect on the distal tubules in the kidney. Spironolactone competes with aldosterone for cell receptor sites in the distal tubules while inducing urinary excretion of sodium and reducing excretion of potassium and hydrogen ions. USES •Treats hypertension and edema. •Reduces edema in clients with severe heart failure. CONTRAINDICATIONS •Hypersensitivity or renal failure •Anuria •Hyperkalemia PRECAUTIONS •Renal dysfunction SIDE EFFECTS •**Hyperkalemia, hyponatremia •Weakness •Dehydration •Hyperglycemia, hirsuitism, menstrual irregularities, gynecomastia •Impotence, deepening of voice NURSING IMPLICATIONS 1.*Monitor intake and output, and †watch for cardiac dysrhythmias. 2.*Monitor levels of electrolytes (e.g., potassium, sodium). 3.‡Teach client to report cramps, weakness, fatigue, or nausea. †Serious/life-threatening implications

Clopidogrel (Plavix)

CLOPIDOGREL (PLAVIX) Classification Antiplatelet ActionSuppresses platelet aggregation in arterial circulation; antiplatelet action occurs within 2 hours of administration. Uses •Prevent occlusion of coronary stents •Prevent/reduce thrombotic problems, such as MI, stroke, peripheral arterial disorders Contraindications and Precautions •Active bleeding •Hypersensitivity, breast-feeding, renal and hepatic disease Side Effects •Abdominal pain, dyspepsia, diarrhea (concern with GI bleeding) •Bleeding—epistaxis, purpura • Rash -Nursing Implications -May administer with food to diminish gastrointestinal (GI) upset. -Teach patient to report any unusual bleeding or bruising (hematuria, tarrystools, epistaxis). -Teach patient that if surgery is scheduled, medication may be held 5 days before surgery. -Platelet counts may be monitored. Patient should notify all health care providers regarding the medication. -Should not be taken with proton pump inhibitors (Prilosec). -platelet counts before beginning then weekly

Felodipine (Plendil)

Calcium Channel Blockers (CCBs)

Nifedipine (Procardia)

Calcium Channel Blockers (CCBs)

Verapamil (Calan,Isoptin)

Calcium Channel Blockers (CCBs)

Amlodipine (Norvasc)

Calcium Channel Blockers (CCBs) -Amlodipine (Norvasc) is currently the most popular CCB of the dihydropyridine subclass. -It is indicated for both angina and hypertension and is available only for oral use.

Diltiazem (Cardizem)

Calcium Channel Blockers (CCBs) -Diltiazem is the only benzothiazepine CCB. -It has a particular affinity for the cardiac conduction system and is very effective for the treatment of angina pectoris resulting from coronary insufficiency and hypertension. -It is one of the few CCBs that are also available in parenteral form, for which it is used in the treatment of atrial fibrillation and flutter along with paroxysmal supraventricular tachycardia. -Several sustained-delivery formulations of diltiazem are available, which can be confused with each other. -For example, there is Cardizem SR, which is taken twice a day, and Cardizem CD, which is taken once a day. -In addition to other brands of these two dosage forms, the drug is also available in several strengths of immediate-release capsule as well as in intravenous form.

Simvastatin(Zocor)

DRUG ALERT— Simvastatin (Zocor) •Increased risk for rhabdomyolysis when also used with gemfibrozil (Lopid) or niacin. •Signs of rhabdomyolysis: ↑ creatine kinase levels, muscle tenderness. -Reduce the synthesis of cholesterol and increase LDL receptors in liver. -Block synthesis of cholesterol in liver -Lowers LDL and triglycerides -Increases HDL -Decreases inflammation

No grapefruit drugs

Drug Interactions and Grapefruit CAUTION *Grapefruit inhibits intestinal enzymes and decreases absorption with Tegretol, Buspar, Mevacor, calcium channel blockers, benzodiazepines (Halcion, Valium), cyclosporine (Sandimmune), and saquinavir (Invirase). EFFECT OF GRAPEFRUIT ON MEDICATIONS Grapefruit and grapefruit juice are metabolized in the liver by the same enzyme (CYP3A4, an isozyme of cytochrome P450) that metabolizes many drugs. When the liver has too many substances to metabolize, the enzymes focus on metabolizing grapefruit while ignoring the medication. †Because the medication is not being metabolized, it can build up to a dangerous level and can lead to intense peak effects. The more grapefruit juice the client drinks, the greater the inhibition. NURSING IMPLICATIONS 1.‡Teach the client to avoid foods containing grapefruit or grapefruit juice with prescribed drugs such as calcium channel blockers, Tegretol, Buspar, and Mevacor. 2.†Does not affect intravenous (IV) preparations of the medications. 3.With Sandimmune and Invirase, the increased blood level that occurs with consuming grapefruit can intensify the therapeutic effects, which can lead to a poor outcome. If levels rise too quickly with Sandimmune, nephrotoxicity and hepatotoxicity can occur.

ferrous sulfate

Ferrous sulfate is the most frequently used form of oral iron. Ferrous sulfate (FeSO4) is dosed as 300 mg two to three times a day for most adult patients. Confusion arises with ferrous sulfate, because the dose is 300 mg, but many commercially available products are 324 mg.

HMG-CoA Reductase Inhibitors (Statins)

HMG-Co A Reductase Inhibitors (Statins) Beta-Adrenergic EXAMPLES Atorvastatin (Lipitor), simvastatin (Zocor), pravastatin (Pravachol), lovastatin (Mevacor), rosuvastatin (Crestor) ACTION Lower cholesterol levels by inhibiting the formation of HMG-Co A reductase, which is an enyzme that is required for the liver to synthesize cholesterol. USES •Hypercholesterolemia •Primary and secondary prevention of cardiovascular events •Clients with type 2 diabetes and coronary heart disease CONTRAINDICATIONS •Hepatitis, pregnancy PRECAUTIONS •Liver disease •Excessive alcohol use SIDE EFFECTS •Myopathy—rhabdomyolysis (severe form) •Hepatoxicity—liver injury with increases in serum transaminases NURSING IMPLICATIONS 1.‡Instruct client to report unexplained muscle pain or tenderness. 2.*Monitor liver function studies. 3.‡Inform women of childbearing age about the potential for fetal harm should they become pregnant. 4.*Administer medication in the evening without regard to meals. 5.‡Instruct client about dietary changes to reduce weight and cholesterol.

iron dextran

Iron dextran (INFeD, Dexferrum) is a colloidal solution of iron (as ferric hydroxide) and dextran. It is intended for intravenous or intramuscular use for treatment of iron deficiency. Anaphylactic reactions to iron dextran, including major orthostatic hypotension and fatal anaphylaxis

Minoxidil (Loniten)

LONITEN must be used in conjunction with a diuretic in patients relying on renal function for maintaining salt and water balance -antihypertensive vasodilator -side effects-salt and water retention -possible congestive heart failure

Mannitol (Osmitrol)

Mannitol (Osmitrol) is the prototypical osmotic diuretic. -Its use is contraindicated in patients with a known hypersensitivity to it as well as in those with anuria, severe dehydration, pulmonary congestion, or cerebral hemorrhage. -Treatment is terminated if severe cardiac or renal impairment develops after the initiation of therapy. -It is available only in parenteral form as 5%, 10%, 15%, 20%, and 25% solutions for intravenous injection. -Mannitol may crystallize when exposed to low temperatures. -Because of this, mannitol is always administered intravenously through a filter, and vials of the drug are often stored in a warmer. -Before administering mannitol, visually inspect the mannitol container for precipitants. -Mannitol is classified as a pregnancy category C drug.

Nitrates

Nitroglycerin -CLASSIFICATION Nitrate vasodilator -ACTION Relaxes vascular (arterial and venous) with more prominent effects on veins, which decreases preload. Arteriolar relaxation reduces systemic vascular resistance, which decreases afterload. -USES •Relief of anginal pain •In conjunction with beta blockers or calcium channel blockers to suppress tachycardia -CONTRAINDICATIONS AND PRECAUTIONS •Hypersensitive clients, severe anemia •Erectile dysfunction medications (Viagra) •Severe hepatic or renal disease and use of other vasodilators •Beta blockers, verapamil, diltiazem SIDE EFFECTS •Orthostatic hypotension, headaches; tachycardia, dry mouth, blurred vision NURSING IMPLICATIONS 1.‡Clients with angina pectoris should carry nitrates with them at all times. 2.‡Teach proper storage for freshness (tingling, fizzle sensation under tongue). Discard unused medication after 24 months. 3.‡Teach client to call 9-1-1, if pain is not relieved within 5 minutes of taking. May take one tablet every 5 minutes for a total of three tablets while waiting for emergency care. 4.Avoid alcoholic beverages during nitrate therapy. 5.Avoid swallowing or chewing sustained release tablets to help the drug reach the gastrointestinal system. 6.*Rotate transdermal patches and remove after 12 to 14 hours to have a "patch free" interval of 10 to 12 hours daily.

ferrous fumarate

The ferrous fumarate iron salts (Femiron) contain the largest amount of iron per gram of salt consumed. Ferrous sulfate and ferric gluconate are two other forms of iron that are commonly used. Ferrous fumarate is 33% elemental iron; therefore, a 325-mg tablet of ferrous fumarate provides 107 mg of elemental iron. Ferrous fumarate is available only for oral use.

Buspirone (Buspar), Calcium Channel Blockers (CCBs), Amlodipine (Norvasc), Diltiazem (Cardizem), Felodipine (Plendil), Nifedipine (Procardia), Verapamil (Calan Isoptin), Carbamazepine (Tegretol), Lovastatin (Mevacor)

no grapefruit drugs