Drug

Lacosamide (Vimpat)

Actions and Uses. Lacosamide [Vimpat] is indicated for add-on therapy of partial-onset seizures in patients age 17 years and older. Benefits appear to derive from slow inactivation of sodium channels, resulting in stabilization of hyperexcitable neuronal membranes and subsequent inhibition of repetitive firing. In patients with refractory partial-onset seizures, adding lacosamide to the regimen reduced seizure frequency by 50% or more in roughly 40% of those treated. Compared with other drugs for partial onset seizures, lacosamide has two advantages. First, it has few drug interactions. Second, it can be administered IV as well as orally. Pharmacokinetics. Lacosamide undergoes complete absorption following oral administration, and hence oral doses produce the same effect as an equivalent IV dose. Drug levels peak 1 to 4 hours after oral dosing, and then decline with a half-life of 13 hours. Elimination is by a combination of hepatic metabolism and renal excretion. Adverse Effects. Lacosamide is generally well tolerated. The most common adverse effects are dizziness, headache, diplopia, and nasopharyngitis. Other effects include vomiting, fatigue, incoordination, blurred vision, tremor, somnolence, and cognitive changes (eg, impaired memory, confusion, attention disruption). Lacosamide can prolong the PR interval, so it should be used with caution in patients with cardiac conduction problems, and in those taking other drugs that prolong the PR interval. About 1% of patients experience euphoria. As a result, lacosamide is classified as a Schedule V drug under the Controlled Substances Act. Like other AEDs, lacosamide carries a small risk of suicidal thoughts or behavior. Drug Interactions. Lacosamide has few drug interactions. In clinical trials, it had little effect on plasma levels of other AEDs; however, cabamazapine, fosphenytoin, phenytoin, and phenobarbital may decrease the serum concentration of lacosamide. As noted, lacosamide should be used with caution in patients taking other drugs that can prolong the PR interval (eg, beta blockers, calcium channel blockers). In patients with severe hepatic impairment, lacosamide should be avoided. Like other AEDs, lacosamide should be withdrawn gradually.

Quetiapine (Seroquel)

Actions and Uses. Quetiapine [Seroquel] is an SGA indicated for schizophrenia, major depression, and acute episodes of mania and depression in patients with bipolar disorder. In patients with schizophrenia, the drug can improve positive symptoms, negative symptoms, and cognitive function. Like other SGAs, quetiapine produces strong blockade of 5-HT2 receptors and weaker blockade of D2 receptors. Blockade of both receptor types is believed responsible for beneficial effects. In addition to blocking receptors for serotonin and dopamine, quetiapine blocks H1 receptors and alpha-adrenergic receptors, but does not block receptors for acetylcholine. Pharmacokinetics. Quetiapine is well absorbed following oral administration. The drug undergoes extensive hepatic metabolism, mainly by CYP3A4, followed by excretion in the urine and feces. The half-life is 6 hours. Adverse Effects. Quetiapine carries a moderate risk of serious metabolic effects (ie, weight gain, diabetes, and dyslipidemia). As with other SGAs, the risk of EPS is low at therapeutic doses. Despite structural similarity to clozapine, quetiapine does not pose a risk of agranulocytosis. Common side effects include sedation (from H1 blockade) and orthostatic hypotension (from alpha blockade). Like other antipsychotics, quetiapine increases the risk of death in older-adult patients with dementia-related psychosis. Cataracts are a concern. Cataracts developed in dogs fed 4 times the maximum human dose for 6 or 12 months. Lens changes have also developed in patients; quetiapine may have been the cause. Because quetiapine may pose a risk of cataracts, the manufacturer recommends examining the lenses for cataracts at baseline and every 6 months thereafter. Like ziprasidone, quetiapine can prolong the QT interval, thereby posing a risk of torsades de pointes. Accordingly, quetiapine should not be given to patients with risk factors for torsades de pointes (eg, hypokalemia; hypomagnesemia; bradycardia; congenital QT prolongation; a history of dysrhythmias, myocardial infarction, or severe heart failure) or to patients taking drugs that prolong the QT interval. Drug Interactions. Metabolism of quetiapine is accelerated by drugs that induce CYP3A4 (eg, phenytoin, rifampin). As a result, a larger dose of quetiapine may be needed to maintain antipsychotic effects. Conversely, drugs that inhibit CYP3A4 (eg, ketoconazole, itraconazole, fluconazole, erythromycin) may increase levels of quetiapine, and may thereby cause toxicity. Caution is advised. As noted, quetiapine should not be combined with other drugs that prolong the QT interval. Agents to avoid include tricyclic antidepressants, thioridazine, certain antidysrhythmic drugs (eg, amiodarone, dofetilide, quinidine), and certain antibiotics (eg, clarithromycin, erythromycin, moxifloxacin). Preparations. Quetiapine is available in immediate-release tablets (25, 50, 100, 200, 300, and 400 mg) marketed as Seroquel and in extended-release tablets (50, 150, 200, 300, and 400 mg) marketed as Seroquel XR. For patients who may be especially sensitive to quetiapine (eg, older adults, those with hepatic impairment, those predisposed to hypotension), a slower titration rate and lower maintenance dosage may be advisable.

Rivastigmine (Exelon)

Alzheimer's

Magnesium hydroxide (Milk of Magnesia)

Antacid and laxative It can treat constipation, upset stomach, and heartburn. Indications As a: • Laxative, • Bowel evacuant in preparation for surgical/radiographic procedures.. Action • Essential for the activity of many enzymes. • Play an important role in neurotransmission and muscular excitability. • Are osmotically active in GI tract, drawing water into the lumen and causing peristalsis. Therapeutic Effects: • Replacement in deficiency states. • Evacuation of the colon. Adverse Reactions/Side Effects* GI: diarrhea. Derm: flushing, sweating.

Rivaroxaban (Xarelto)

Anticoagulant, Factor Xa Inhibitor

Carbamazepine (Tegretol)

Anticonvulsant bipolar nerve pain

Pregabalin (Lyrica)

Anticonvulsant/Antineuralgic

Budesonide - Formoterol (Symbicort)

Asthma, COPD Adverse Effects • COMMON ◊ Gastrointestinal: Oral candidiasis (1.4% to 6%), Stomach ache (1.1% to 6.5%), Vomiting (1.4% to 3.2%) ◊ Immunologic: Oral candidiasis (1.4% to 3.2%) ◊ Musculoskeletal: Backache (1.6% to 3.2%) ◊ Neurologic: Headache (Up to 11.3%) ◊ Respiratory: Nasal congestion (2.5% to 3.2%), Nasopharyngitis (7.3% to 10.5%), Pain in throat (6.1% to 8.9%), Sinusitis (3.5% to 5.8%), Upper respiratory infection (Up to 10.5%) ◊ Other: Influenza (2.4% to 3.2%) • SERIOUS ◊ Endocrine metabolic: Hypokalemia ◊ Ophthalmic: Cataract, Glaucoma, Raised intraocular pressure ◊ Respiratory: Death, asthma-related Class • Adrenal Glucocorticoid • Antiasthma • Antiasthma, Anti-Inflammatory/Bronchodilator Combination • Beta-2 Adrenergic Agonist • Sympathomimetic After inhalation, rinse mouth with water without swallowing.

Propanolol (Inderal)

Beta blocker It can treat high blood pressure, chest pain (angina), and uneven heartbeat (atrial fibrillation). It can also treat tremors and proliferating infantile hemangioma. In addition, it can prevent migraine headaches.

Cetrizine (Zyrtec)

Classification(s) Ther. Class. allergy, cold and cough remedies antihistamines Pharm. Class. piperazines (peripherally selective) Indications Relief of allergic symptoms caused by histamine release including: • Seasonal and perennial allergic rhinitis, • Chronic urticaria.. Action • Antagonizes the effects of histamine at H1-receptor sites; does not bind to or inactivate histamine. • Anticholinergic effects are minimal and sedation is dose related. Therapeutic Effects: Decreased symptoms of histamine excess (sneezing, rhinorrhea, ocular tearing and redness, pruritus). Adverse Reactions/Side Effects* CNS: dizziness, drowsiness (significant with doses >10 mg/day), fatigue. Derm: acute generalized exanthematous pustulosis. EENT: pharyngitis. GI: dry mouth.

Famotidine (Pepcid)

Classification(s) Ther. Class. anti-ulcer agents Pharm. Class. histamine H2 antagonists Indications • Short-term treatment of active duodenal ulcers and benign gastric ulcers. • Maintenance therapy for duodenal ulcers after healing of active ulcer(s). • Management of gastroesophageal reflux disease (GERD). • Treatment of heartburn, acid indigestion, and sour stomach (OTC use). • Management of gastric hypersecretory states (Zollinger-Ellison syndrome). • Prevention and treatment of stress-induced upper GI bleeding in critically ill patients. Unlabeled Use(s): • Management of GI symptoms associated with the use of NSAIDs. • Prevention of stress ulceration or aspiration pneumonitis. • Prevention of acid inactivation of supplemental pancreatic enzymes in patients with pancreatic insufficiency. • Management of urticaria. Action Inhibits the action of histamine at the H2-receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. Therapeutic Effects: • Healing and prevention of ulcers. • Decreased symptoms of gastroesophageal reflux. • Decreased secretion of gastric acid. Adverse Reactions/Side Effects* CNS: confusion, dizziness, drowsiness, hallucinations, headache. CV: ARRHYTHMIAS. GI: constipation, diarrhea, nausea. GU: sperm count, erectile dysfunction. Endo: gynecomastia. Hemat: AGRANULOCYTOSIS, APLASTIC ANEMIA, anemia, neutropenia, thrombocytopenia. Local: pain at IM site. Misc: hypersensivity reactions.

Fluoxetine (Prozac)

Classification(s) Ther. Class. antidepressants Pharm. Class. selective serotonin reuptake inhibitors (SSRIs) Indications • Major depressive disorder. • Obsessive compulsive disorder (OCD). • Bulimia nervosa. • Panic disorder. • Acute treatment of depressive episodes associated with bipolar I disorder (when used with olanzapine). • Treatment-resistant depression (when used with olanzapine). Sarafem and Selfemra: • Premenstrual dysphoric disorder (PMDD). Unlabeled Use(s): Anorexia nervosa: • ADHD, • Diabetic neuropathy, • Fibromyalgia, • Obesity, • Raynaud's phenomenon, • Social anxiety disorder (social phobia), • Posttraumatic stress disorder (PTSD).. Action Selectively inhibits the reuptake of serotonin in the CNS. Therapeutic Effects: • Antidepressant action. • Decreased behaviors associated with: • panic disorder, • bulimia. • Decreased mood alterations associated with PMDD. Adverse Reactions/Side Effects* CNS: NEUROLEPTIC MALIGNANT SYNDROME, SEIZURES, SUICIDAL THOUGHTS, anxiety, drowsiness, headache, insomnia, nervousness, abnormal dreams, dizziness, fatigue, hypomania, mania, weakness. EENT: mydriasis, stuffy nose, visual disturbances. Resp: cough. CV: TORSADES DE POINTES, chest pain, palpitations, QT interval prolongation. GI: diarrhea, abdominal pain, abnormal taste, anorexia, constipation, dry mouth, dyspepsia, nausea, vomiting, weight loss. GU: sexual dysfunction, urinary frequency. Derm: sweating, pruritus, erythema nodusum, flushing, rashes. Endo: dysmenorrhea. F and E: hyponatremia. MS: arthralgia, back pain, myalgia. Neuro: tremor. Misc: SEROTONIN SYNDROME, allergic reactions, fever, flu-like syndrome, hot flashes, sensitivity reaction. Evaluation/Desired Outcomes • Increased sense of well-being. • Renewed interest in surroundings. May require 1-4 wk of therapy to obtain antidepressant effects. • Decrease in obsessive-compulsive behaviors. • Decrease in binge eating and vomiting in patients with bulimia nervosa. • Decreased incidence frequency of panic attacks. • Decreased mood alterations associated with PMDD.

Metaformin (Glucophage)

Classification(s) Ther. Class. antidiabetics Pharm. Class. biguanides Indications Management of type 2 diabetes mellitus; may be used with diet, insulin, or sulfonylurea oral hypoglycemics. Action • Decreases hepatic glucose production. • Decreases intestinal glucose absorption. • Increases sensitivity to insulin. Therapeutic Effects: Maintenance of blood glucose. Adverse Reactions/Side Effects* GI: abdominal bloating, diarrhea, nausea, vomiting, unpleasant metallic taste. F and E: LACTIC ACIDOSIS. Misc: decreased vitamin B12 levels. Evaluation/Desired Outcomes Control of blood glucose levels without the appearance of hypoglycemic or hyperglycemic episodes. Control may be achieved within a few days, but full effect of therapy may be delayed for up to 2 wk. If patient has not responded to metformin after 4 wk of maximum dose therapy, an oral sulfonylurea may be added. If satisfactory results are not obtained with 1-3 mo of concurrent therapy, oral agents may be discontinued and insulin therapy instituted.

Simethicone (Mylicon)

Classification(s) Ther. Class. antiflatulent Indications Relief of painful symptoms of excess gas in the GI tract that may occur postoperatively or as a consequence of: • Air swallowing, • Dyspepsia, • Peptic ulcer, • Diverticulitis.. Action • Causes the coalescence of gas bubbles. • Does not prevent the formation of gas. Therapeutic Effects: Passage of gas through the GI tract by belching or passing flatus. Adverse Reactions/Side Effects* None significant.

butalbital-acetaminophen-caffeine

Classification(s) Ther. Class. nonopioid analgesics (combination with barbiturate) Pharm. Class. barbiturates Indications Relief of the symptom complex of tension (or muscle contraction) headaches (use should be short-term only as the butalbital component may be habit-forming). Action Contains an analgesic (acetaminophen) for relief of pain, a barbiturate (butalbital) for its sedative effect, and caffeine, which may be of benefit in tension headaches. Therapeutic Effects: Decreased severity of pain with some sedation. Adverse Reactions/Side Effects* CNS: drowsiness, confusion, delirium, depression, dizziness, excitation, headache (with chronic use), insomnia, irritability, lethargy, nervousness, numbness, tingling. EENT: earache, nasal congestion, tinnitus. Resp: respiratory depression. CV: palpitations, tachycardia. GI: constipation, dry mouth, dysphagia, flatulence, heartburn. Derm: dermatitis, pruritis, rash, sweating. MS: leg pain, muscle weakness. Misc: fever, physical dependence, psychological dependence, tolerance.

nicotine (nicoderm)

Classification(s) Ther. Class. smoking deterrents Indications Adjunct therapy (with behavior modification) in the management of nicotine withdrawal in patients desiring to give up cigarette smoking. Action Provides a source of nicotine during controlled withdrawal from cigarette smoking. Therapeutic Effects: Lessened sequelae of nicotine withdrawal (irritability, insomnia, somnolence, headache, and increased appetite). Mostly metabolized by the liver. Small amounts are metabolized by kidneys and lungs; 10-20% excreted unchanged by kidneys. Adverse Reactions/Side Effects* CNS: headache, insomnia, abnormal dreams, dizziness, drowsiness, impaired concentration, nervousness, seizures, weakness. EENT: sinusitis, gum, pharyngitis, nasal spray, nasopharyngeal irritation, sneezing, watering eyes, change in smell, earache, epistaxis, eye irritation, hoarseness, inhaler, local mouth/throat irritation. Resp: Nasal spray, inhaler—cough, dyspnea. CV: tachycardia, chest pain, hypertension. GI: abdominal pain, abnormal taste, constipation, diarrhea, dry mouth, dyspepsia, hiccups, nausea, vomiting, gum, belching, appetite, salivation, oral injury, sore mouth. Derm: transdermal—burning at patch site, erythema, pruritus, cutaneous hypersensitivity, rash, sweating. Endo: dysmenorrhea. MS: arthralgia, back pain, myalgia, gum, jaw muscle ache. Neuro: paresthesia. Misc: allergy.

Hydralazine (Apresoline)

Classification(s) Ther. Class. vasodilators Pharm. Class. vasodilators nitrates Adverse Reactions/Side Effects* CNS: dizziness, drowsiness, headache. CV: tachycardia, angina, arrhythmias, edema, orthostatic hypotension. GI: diarrhea, nausea, vomiting. Derm: rash. F and E: sodium retention. MS: arthralgias, arthritis. Neuro: peripheral neuritis. Misc: drug-induced lupus syndrome.

Albuterol - ipratropium (Duoneb)

DuoNeb (ipratropium bromide and albuterol sulfate) Inhalation Solution is a combination of the β2-adrenergic bronchodilator, albuterol sulfate, and the anticholinergic bronchodilator, ipratropium bromide.

Cyanocobalamin (Vitamin B12)

If your vitamin B12 level is a little low, you might not have any symptoms. A very low level can cause anemia, which is a decrease in red blood cells. Other symptoms include: • weakness • fatigue • tingling or numbness • pale skin • fast heartbeat • shortness of breath • bloating or gas • constipation or diarrhea • loss of appetite • depression • dementia.

Sodium Phosphate Enema (Fleet)

Indications • Intermittent treatment of chronic constipation. OsmoPrep: • Cleansing of the bowel as a preparation for colonoscopy. Action • Osmotically active in the lumen of the GI tract. • Produces laxative effect by causing water retention and stimulation of peristalsis. • Stimulates motility and inhibits fluid and electrolyte absorption from the small intestine. Therapeutic Effects: • Relief of constipation. • Emptying of the bowel. Adverse Reactions/Side Effects* CNS: Visicol—dizziness, headache. CV: ARRHYTHMIAS. GI: cramping, nausea, colonic aphtous ulcerations, ischemic colitis, OsmoPrep, abdominal bloating, abdominal pain, vomiting. F and E: hyperphosphatemia, hypocalcemia, hypokalemia, sodium retention. GU: renal dysfunction.

Menthol (HALLS) lozenge

It is used to relieve coughing. It is used to treat a sore throat. Suck oral lozenge. Do not chew, break, or crush it. Do not swallow it whole.

Lactulose liquid

Lactulose is a synthetic sugar used to treat constipation. It is broken down in the colon into products that pull water out from the body and into the colon. This water softens stools. Lactulose is also used to reduce the amount of ammonia in the blood of patients with liver disease. Ther. Class. laxatives Pharm. Class. osmotics Indications • Treatment of chronic constipation. • Adjunct in the management of portal-systemic (hepatic) encephalopathy (PSE). Action • Increases water content and softens the stool. • Lowers the pH of the colon, which inhibits the diffusion of ammonia from the colon into the blood, thereby reducing blood ammonia levels. Therapeutic Effects: • Relief of constipation. • Decreased blood ammonia levels with improved mental status in PSE. Adverse Reactions/Side Effects* GI: belching, cramps, distention, flatulence, diarrhea. Endo: hyperglycemia (diabetic patients).

Levetiracetam (Keppra)

Levetiracetam [Keppra] is a unique agent that is chemically and pharmacologically different from all other AEDs. How levetiracetam acts is unknown; however, we know that it does not bind to receptors for GABA or any other known neurotransmitter. In the United States, the drug is approved for adjunctive therapy of (1) myoclonic seizures in adults and adolescents age 12 years and older, (2) partial-onset seizures in adults and children age 4 years and older, and (3) primary generalized tonic-clonic seizures in adults and children age 6 years and older. Unlabeled uses include migraine, bipolar disorder, and new-onset pediatric epilepsy. In Europe, the drug is approved for monotherapy of partial seizures, for which it is highly effective. Following oral dosing, levetiracetam undergoes rapid and complete absorption both in the presence and absence of food. Metabolism is minimal and not mediated by hepatic cytochrome P450 isoenzymes. Levetiracetam is excreted in the urine, largely (66%) unchanged. Adverse effects are generally mild to moderate. The most common are drowsiness and asthenia (lack of strength, weakness). Neuropsychiatric symptoms (agitation, anxiety, depression, psychosis, hallucinations, depersonalization) occur in less than 1% of patients. In contrast to other AEDs, levetiracetam does not impair speech, concentration, or other cognitive functions. Safety for use during pregnancy or breast-feeding has not been determined. However, because it can be detected in breast milk, breast-feeding is not recommended by the manufacturer. Unlike most other AEDs, levetiracetam does not interact with other drugs. It does not alter plasma concentrations of oral contraceptives, warfarin, digoxin, or other AEDs. These benefits are primarily attributable to the fact that levetiracetam is not metabolized by P450 isoenzymes. Because levetiracetam is eliminated by the kidneys, dosage should be reduced in patients with significant renal impairment.

benzocaine

Action Inhibit initiation and conduction of sensory nerve impulses. Therapeutic Effects: Local anesthesia with subsequent loss of sensation or relief of pain and/or pruritus. Pharmacokinetics Absorbtion: Benzocaine is poorly absorbed through intact skin. Other agents may be readily absorbed. Degree of absorption with surface area; presence of lesions, cuts, or abrasions; and amount of agent applied. Distribution: Unknown. Metabolism and Excretion: Ester-type agents (PABA derivatives, benzocaine) are metabolized by plasma and liver cholinesterases. Small amounts of amide-type agents (dibucaine) that may be absorbed are mostly metabolized by the liver. Adverse Reactions/Side Effects* EENT: mucosal use— or absent gag reflex. Derm: topical use—burning, edema, irritation, stinging, tenderness, urticaria. Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS.

Haloperidol Lactate (Haldol)

Actions and Uses. Haloperidol [Haldol], a member of the butyrophenone family, is the prototype of the high-potency FGAs. Principal indications are schizophrenia and acute psychosis. In addition, haloperidol is a preferred agent for Tourette's syndrome. The drug can also be used to control severe behavior problems in children (eg, combative, explosive hyperexcitability unrelated to any immediate provocation), but only as a last resort. Haloperidol is used more than other FGAs. Pharmacokinetics. Haloperidol may be administered PO or IM. Oral bioavailability is about 60%. Hepatic metabolism is extensive. Parent drug and metabolites are excreted in the urine. Adverse Effects. As indicated in Table 31-2, early extrapyramidal reactions (acute dystonia, parkinsonism, akathisia) occur frequently, whereas sedation, hypotension, and anticholinergic effects are uncommon. Note that the incidence of these reactions is opposite to that seen with the low-potency agents. However, the incidence of TD is the same as with all other FGAs. Neuroendocrine effects—galactorrhea, gynecomastia, menstrual irregularities—are seen occasionally. NMS, photosensitivity, convulsions, and impotence are rare. Haloperidol can prolong the QT interval, and hence may pose a risk of serious dysrhythmias, especially when given IV and/or in high doses. The drug should be used with caution in patients with dysrhythmia risk factors, including long QT syndrome, hypokalemia or hyperkalemia, or a history of dysrhythmias, heart attack, or severe heart failure. Combined use with other QT-prolonging drugs (eg, amiodarone, erythromycin, quinidine) should be avoided.

Levothyroxine (Levothroid, Synthroid)

Levothyroxine [Levothroid, Synthroid, others] is a synthetic preparation of thyroxine, a naturally occurring thyroid hormone. The structure of levothyroxine is identical to that of the natural hormone. Levothyroxine is the drug of choice for most patients who require thyroid hormone replacement. Consequently, levothyroxine will serve as our prototype for the thyroid hormone preparations. Pharmacokinetics Absorption. Absorption of oral levothyroxine is reduced by food. Accordingly, to minimize variability in blood levels, levothyroxine should be taken on an empty stomach in the morning, at least 30 to 60 minutes before breakfast. Conversion to T3. Much of an administered dose of levothyroxine is converted to T3 in the body. As a result, levothyroxine can produce nearly normal levels of both T3 and T4. Hence, for most patients, there is no need to give T3 along with levothyroxine. Half-Life and Plasma Levels. Because levothyroxine is highly protein bound (about 99.97%), the hormone has a prolonged half-life (about 7 days). From a clinical perspective, this long half-life is good news and bad news. The good news is that hormone levels remain fairly steady, even with once-a-day dosing, which makes levothyroxine well suited for lifelong therapy. The bad news is that it takes about 1 month (four half-lives) for plasma levels of levothyroxine to reach plateau (steady state). As a result, onset of full effects is delayed. Therapeutic Uses Levothyroxine is indicated for all forms of hypothyroidism, regardless of cause. The drug is used for cretinism, myxedema coma, simple goiter, and primary hypothyroidism in adults and children. Levothyroxine is also used to treat hypothyroidism resulting from insufficient TSH (secondary to pituitary malfunction) and from insufficient TRH (secondary to hypothalamic malfunction). In addition, levothyroxine is used to maintain proper levels of thyroid hormones following thyroid surgery, irradiation, and treatment with antithyroid drugs. Levothyroxine and other thyroid hormones should not be taken to treat obesity. These hormones will accelerate metabolism and promote weight reduction only if the dosage is high enough to establish a pathologic (hyperthyroid) state. Adverse Effects When administered in appropriate dosage, levothyroxine rarely causes adverse effects. With an acute overdose, thyrotoxicosis may result. Signs and symptoms include tachycardia, angina, tremor, nervousness, insomnia, hyperthermia, heat intolerance, and sweating. The patient should be informed about these signs and instructed to notify the prescriber if they develop. Chronic overdosage is associated with accelerated bone loss and increased risk of atrial fibrillation, especially in older adults. Loss of bone increases the risk of fractures.

magnesium oxide (Mag-Ox)

Magnesium deficiency; Prophylaxis Upset stomach, Acid indigestion

Oxybutinin (Ditropan)

Muscarinic antagonist, used to treat overactive bladder

Potassium Chloride (KLOR-CON)

POTASSIUM Intravenous potassium must be infused slowly (generally no faster than 10 mEq/hr in adults). Potassium chloride must never be administered by IV push. In fact, potassium chloride is one of the agents used in lethal injections, as rapid infusion results in cardiac arrest. Oral Potassium Chloride Uses, Dosage, and Preparations. Oral potassium chloride may be used for both prevention and treatment of potassium deficiency. Dosages for prevention range from 16 to 24 mEq/day. Dosages for deficiency range from 40 to 100 mEq/day. Oral potassium chloride is available in solution and in solid formulations: immediate-release tablets, sustained-release tablets, effervescent tablets, and powders. The sustained release tablets (eg, Klor-Con, Micro-K) are preferred because they are more convenient and better tolerated than the other formulations, and hence offer the best chance of patient adherence. Adverse Effects. Potassium chloride irritates the GI tract, frequently causing abdominal discomfort, nausea, vomiting, and diarrhea. With the exception of the sustained-release tablets, solid formulations can produce high local concentrations of potassium, resulting in severe intestinal injury (ulcerative lesions, bleeding, perforation); death has occurred. To minimize GI effects, oral potassium chloride should be taken with meals or a full glass of water. If symptoms of irritation occur, dosing should be discontinued. Rarely, oral potassium chloride produces hyperkalemia. This dangerous development is much more likely with IV therapy. Intravenous Potassium Chloride. Intravenous potassium chloride is indicated for prevention and treatment of hypokalemia. Intravenous solutions must be diluted (preferably to 40 mEq/L or less) as they are extremely irritating to the veins. The principal complication is hyperkalemia, which can prove fatal. To reduce the risk of hyperkalemia, serum potassium levels should be measured before the infusion and periodically throughout the treatment interval. Also, renal function should be assessed before and during treatment to ensure adequate output of urine. If renal failure develops, the infusion should be stopped immediately. Changes in the electrocardiogram (ECG) can be an early indication that potassium toxicity is developing. Contraindications to Potassium Use. Potassium should be avoided under conditions that predispose to hyperkalemia (eg, severe renal impairment, use of potassium-sparing diuretics, hypoaldosteronism). Potassium must also be avoided when hyperkalemia already exists.

Pantoprazole (Protonix)

Pantoprazole [Protonix, Protonix I.V., Pantoloc ] is similar to omeprazole and the other PPIs (Proton Pump Inhibitors). The drug is approved for treating GERD and hypersecretory states. Like other PPIs, pantoprazole is well tolerated. Like lansoprazole, pantoprazole may be administered PO or IV. With oral therapy, the most common adverse effects are diarrhea, headache, and dizziness. With IV therapy, the most common adverse effects are diarrhea, headache, nausea, dyspepsia (indigestion), and injection-site reactions, including thrombophlebitis and abscess. With both routes, elevation of gastric pH may increase the risk of pneumonia. Long-term therapy may pose a risk of hypomagnesemia, as well as osteoporosis and fractures. Pantoprazole does not affect cytochrome P450 enzymes, and hence does not affect the metabolism of other drugs.

Rifaximin (Xifaxan)

Rifaximin [Xifaxan] is an oral, nonabsorbable analog of rifampin used to kill bacteria in the gut. Like rifampin, rifaximin inhibits bacterial DNA-dependent RNA polymerase, and thereby inhibits RNA synthesis, resulting in inhibition of protein synthesis and subsequent bacterial death. Rifaximin has two approved uses. The drug was approved initially for traveler's diarrhea caused by E. coli in patients at least 12 years old. Rifaximin is not effective against severe diarrhea associated with fever or bloody stools, and should not be used if these are present. More recently, rifaximin was approved for prevention of hepatic encephalopathy (brain injury) in patients with chronic liver disease. Why does liver disease cause brain injury, and how does rifaximin help? In all of us, intestinal bacteria produce ammonia, a toxic substance that is normally cleared by the liver. However, in patients with liver disease, the liver can't remove much ammonia, and hence it can accumulate to levels that can harm the brain. Rifaximin helps prevent encephalopathy by killing the intestinal bacteria that produce ammonia. Off-label uses for rifaximin include irritable bowel syndrome and recurrent C. difficile infection. Rifaximin is administered by mouth, and very little (< 0.4%) is absorbed. As a result, the drug achieves high concentrations in the intestinal tract, and then is excreted unchanged in the stool. Rifaximin is well tolerated. Gastrointestinal effects—nausea, flatulence, defecation urgency—occur in some patients. Because so little drug is absorbed, systemic effects are minimal. However, studies in rats and rabbits indicate that rifaximin is teratogenic, and hence should not be used by pregnant or breast-feeding women. There have been post marketing reports of hypersensitivity reactions (rash, allergic dermatitis, urticaria, pruritus, angioneurotic edema), but rifaximin has not been clearly identified as the cause.

Venlafaxine (Effexor)

SNRI antidepressant

Sertraline (Zoloft)

Sertraline [Zoloft] is much like fluoxetine: both drugs block reuptake of 5-HT, both relieve symptoms of major depression, both cause CNS stimulation rather than sedation, and both have minimal effects on seizure threshold and the electrocardiogram (ECG). Sertraline is indicated for major depression, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, premenstrual dysphoric disorder, and social anxiety disorder (social phobia). The drug is used off-label to treat generalized anxiety disorder, impulse control disorders, mild dementia-associated agitation in nonpsychotic patients, eating disorders, and paraphilia. Sertraline is slowly absorbed following oral administration. Food increases the extent of absorption. In the blood, the drug is highly bound (99%) to plasma proteins. Sertraline undergoes extensive hepatic metabolism followed by elimination in the urine and feces. The plasma half-life is approximately 1 day. Common side effects include headache, tremor, insomnia, agitation, nervousness, nausea, diarrhea, weight gain, and sexual dysfunction. Treatment may also increase the risk of suicide. Because of the risk of serotonin syndrome, sertraline must not be combined with MAOIs and other serotonergic drugs (see Table 32-3). MAOIs should be withdrawn at least 14 days before starting sertraline, and sertraline should be withdrawn at least 14 days before starting an MAOI. Because of a risk of pimozide-induced dysrhythmias, sertraline (which raises pimozide levels) and pimozide should not be combined. Like fluoxetine and other SSRIs, sertraline poses a risk of hyponatremia, GI bleeding, and NAS and PPHN when used late in pregnancy. Sertraline is available in tablets (25, 50, and 100 mg) and a concentrated oral solution (20 mg/mL). For treatment of depression, the initial adult daily dosage is 50 mg, administered in the morning or evening. After 4 to 8 weeks, the dosage may be increased by 50-mg increments to a maximum of 200 mg/ day. When discontinuing the drug, dosage should be reduced gradually.

Sucralfate (Carafate)

Sucralfate [Carafate, Sulcrate ] is an effective antiulcer medication notable for minimal side effects and lack of significant drug interactions. The drug promotes ulcer healing by creating a protective barrier against acid and pepsin. Under mildly acidic conditions (pH below 4), sucralfate undergoes polymerization and cross-linking reactions. Attachment to the ulcer appears to last up to 6 hours. Pharmacokinetics. Sucralfate is administered orally, and systemic absorption is minimal (3% to 5%). About 90% of each dose is eliminated in the feces. Therapeutic Uses: duodenal ulcers, gastric ulcers. Adverse Effects. Sucralfate has no known serious adverse effects. The most significant side effect is constipation, which occurs in 2% of patients. Because sucralfate is not absorbed, systemic effects are absent. Drug Interactions. Interactions with other drugs are minimal. By raising gastric pH above 4, antacids may interfere with sucralfate's effects. This interaction can be minimized by administering these drugs at least 30 minutes apart. Sucralfate may impede the absorption of some drugs, including phenytoin, theophylline, digoxin, warfarin, and fluoroquinolone antibiotics (eg, ciprofloxacin, norfloxacin). These interactions can be minimized by administering sucralfate at least 2 hours apart from these other drugs.

Donepezil (Aricept)

Ther. Class. Anti-Alzheimer's agents Pharm. Class. cholinergics (cholinesterase inhibitors) Indications Mild, moderate, or severe dementia/neurocognitive disorder associated with Alzheimer's disease. Action Inhibits acetylcholinesterase thus improving cholinergic function by making more acetylcholine available. Therapeutic Effects: • May temporarily lessen some of the dementia associated with Alzheimer's disease. • Enhances cognition. • Does not cure the disease. Partially metabolized by the liver (CYP2D6 and CYP3A4 enyzmes) and partially excreted by kidneys (17% unchanged). Two metabolites are pharmacologically active. Adverse Reactions/Side Effects* CNS: headache, abnormal dreams, depression, dizziness, drowsiness, fatigue, insomnia, syncope, sedation (unusual). CV: atrial fibrillation, hypertension, hypotension, vasodilation. GI: diarrhea, nausea, anorexia, vomiting, weight gain (unusual). GU: frequent urination. Derm: ecchymoses. Metab: hot flashes, weight loss. MS: arthritis, muscle cramps.

Rivastigmine (Exelon)

Ther. Class. Anti-Alzheimer's agents Pharm. Class. cholinergics (cholinesterase inhibitors) Indications PO: • Mild to moderate dementia associated with Alzheimer's disease. Transdermal: • Treatment of mild, moderate, or severe dementia associated with Alzheimer's disease and mild to moderate dementia associated with Parkinson's disease. Action • Enhances cholinergic function by reversible inhibition of cholinesterase. • Does not cure the disease. Therapeutic Effects: • Decreased dementia (temporary) associated with Alzheimer's disease and Parkinson's disease. • Enhanced cognitive ability. Pharmacokinetics Absorbtion: Well absorbed following oral administration. Transdermal patch is slowly absorbed over 8 hr. Distribution: Widely distributed. Metabolism and Excretion: Rapidly and extensively metabolized by the liver; metabolites are excreted by the kidneys. Half-life: PO—1.5 hr; Transdermal—24 hr. Adverse Reactions/Side Effects* CNS: weakness, dizziness, drowsiness, headache, sedation (unusual). CV: edema, heart failure, hypotension. GI: anorexia, dyspepsia, nausea, vomiting, abdominal pain, diarrhea, flatulence, weight gain (unusual). Derm: allergic dermatitis. Neuro: tremor. Misc: fever, weight loss, application reactions (for transdermal patch only).

Fexofenadine (Allegra)

Ther. Class. allergy, cold and cough remedies antihistamines Indications • Relief of symptoms of seasonal allergic rhinitis. • Management of chronic idiopathic urticaria. Action • Antagonizes the effects of histamine at peripheral histamine-1 (H1) receptors, including pruritus and urticaria. • Also has a drying effect on the nasal mucosa. Therapeutic Effects: • Decreased sneezing, rhinorrhea, itchy eyes, nose, and throat associated with seasonal allergies. • Decreased urticaria/hives. Adverse Reactions/Side Effects* CNS: drowsiness, fatigue. GI: dyspepsia. Endo: dysmenorrhea.

Diphenhydramine (Benadryl)

Ther. Class. allergy, cold and cough remedies antihistamines antitussives Indications • Relief of allergic symptoms caused by histamine release including: • Anaphylaxis, • Seasonal and perennial allergic rhinitis, • Allergic dermatoses. • Parkinson's disease and dystonic reactions from medications. • Mild nighttime sedation. • Prevention of motion sickness. • Antitussive (syrup only). Action • Antagonizes the effects of histamine at H1-receptor sites; does not bind to or inactivate histamine. • Significant CNS depressant and anticholinergic properties. Therapeutic Effects: • Decreased symptoms of histamine excess (sneezing, rhinorrhea, nasal and ocular pruritus, ocular tearing and redness, urticaria). • Relief of acute dystonic reactions. • Prevention of motion sickness. • Suppression of cough. Adverse Reactions/Side Effects* CNS: drowsiness, dizziness, headache, paradoxical excitation (increased in children). EENT: blurred vision, tinnitus. CV: hypotension, palpitations. GI: anorexia, dry mouth, constipation, nausea. GU: dysuria, frequency, urinary retention. Derm: photosensitivity. Resp: chest tightness, thickened bronchial secretions, wheezing. Local: pain at IM site.

Hydromorphine (Dilaudid)

Ther. Class. allergy, cold and cough remedies (antitussives) opioid analgesics Pharm. Class. opioid agonists Controlled Substance Schedule: II Indications • Moderate to severe pain (alone and in combination with nonopioid analgesics). • Moderate to severe chronic pain in opioid-tolerant patients requiring use of daily, around-the-clock long-term opioid treatment and for which alternative treatment options are inadequate (extended-release). • Antitussive (lower doses). Action • Binds to opiate receptors in the CNS. • Alters the perception of and response to painful stimuli while producing generalized CNS depression. • Suppresses the cough reflex via a direct central action. Therapeutic Effects: • Decrease in moderate to severe pain. • Suppression of cough. Adverse Reactions/Side Effects* CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp: RESPIRATORY DEPRESSION. CV: hypotension, bradycardia. Endo: adrenal insufficiency. GI: constipation, dry mouth, nausea, vomiting. GU: urinary retention. Derm: flushing, sweating. Misc: physical dependence, psychological dependence, tolerance.

Gabapentin (Neurontin)

Ther. Class. analgesic adjuncts anticonvulsants mood stabilizers Indications • Partial seizures (adjunct treatment) (immediate-release only). • Postherpetic neuralgia. • Restless legs syndrome (Horizant only). Unlabeled Use(s): • Neuropathic pain. • Prevention of migraine headache. • Bipolar disorder. • Anxiety. • Diabetic peripheral neuropathy. Action Mechanism of action is not known. May affect transport of amino acids across and stabilize neuronal membranes. Therapeutic Effects: • Decreased incidence of seizures. • Decreased postherpetic pain. • Decreased leg restlessness. Mechanism of Action. Gabapentin's precise mechanism of action is unknown. The drug is an analog of GABA, but does not directly affect GABA receptors. Rather, it may enhance GABA release, thereby increasing GABA mediated inhibition of neuronal firing. Pharmacokinetics. Gabapentin is rapidly absorbed following oral dosing and reaches peak plasma levels in 2 to 3 hours. Absorption is not affected by food. However, as the dosage gets larger, the percentage absorbed gets smaller because, at high doses, the intestinal transport system for uptake of the drug becomes saturated. Gabapentin is not metabolized and is excreted intact in the urine. Its half-life is 5 to 7 hours. Drug Interactions. Unlike most AEDs, gabapentin is devoid of significant interactions. It doesn't induce or inhibit drug-metabolizing enzymes, and doesn't affect the metabolism of other drugs. As a result, gabapentin is well suited for combined use with other AEDs. Adverse Reactions. Gabapentin is very well tolerated. The most common side effects are somnolence, dizziness, ataxia, fatigue, nystagmus, and peripheral edema. These are usually mild to moderate and often diminish with continued drug use. Patients should avoid driving and other hazardous activities until they are confident they are not impaired. Safety in pregnancy and breast-feeding has not been established. Until further data are available, manufacturers recommend that gabapentin should only be used by nursing women if the benefits of breast-feeding outweigh the risks to the infant.

Pregabalin (Lyrica)

Ther. Class. analgesics anticonvulsants Pharm. Class. gamma aminobutyric acid (GABA) analogues nonopioid analgesics Controlled Substance Schedule: V Indications • Neuropathic pain associated with diabetic peripheral neuropathy. • Postherpetic neuralgia. • Fibromyalgia. • Neuropathic pain associated with spinal cord injury. • Adjunctive therapy of partial-onset seizures in adults. Action Binds to calcium channels in CNS tissues which regulate neurotransmitter release. Does not bind to opioid receptors. Therapeutic Effects: • Decreased neuropathic or post-herpetic pain. • Decreased partial-onset seizures. Therapeutic Uses. Pregabalin has four approved indications: neuropathic pain associated with diabetic neuropathy, postherpetic neuralgia, adjunctive therapy of partial seizures, and fibromyalgia. Mechanism of Action. Although the precise mechanism of action has not been established, we do know that pregabalin can bind with calcium channels on nerve terminals, and can thereby inhibit calcium influx, which in turn can inhibit release of several neurotransmitters, including glutamate, norepinephrine, and substance P. Reduced transmitter release may underlie seizure control and relief of neuropathic pain. Although pregabalin is an analog of GABA, the drug does not bind with GABA receptors or with benzodiazepine receptors, and hence does not work by mimicking or enhancing the inhibitory actions of GABA. Pharmacokinetics. Pregabalin is well absorbed after oral dosing. Plasma levels peak in 1.5 hours. Food reduces the rate of absorption but not the extent. Oral bioavailability is 90% or greater. Pregabalin does not bind with plasma proteins, but does cross the blood-brain and placental barriers. Elimination is renal, 98% as unchanged drug. Metabolism is negligible. The half-life is 6.3 hours. Adverse Effects. Pregabalin can cause a variety of adverse effects. The most common are dizziness and somnolence, which often persist as long as the drug is being taken. Blurred vision may develop during early therapy, but resolves with continued drug use. About 8% of patients experience significant weight gain (7% or more of body weight in just a few months). Other adverse effects include difficulty thinking, headache, peripheral edema, and dry mouth. Postmarketing reports indicate a risk of hypersensitivity reactions, including life-threatening angioedema, characterized by swelling of the face, tongue, lip, gums, throat, and larynx. Patients should discontinue pregabalin immediately at the first sign of angioedema, or any other hypersensitivity reaction (blisters, hives, rash, dyspnea, wheezing). In clinical trials, three patients developed rhabdomyolysis (muscle breakdown). However, it is not clear that pregabalin was the cause. Nonetheless, patients should be instructed to report signs of muscle injury (pain, tenderness, weakness). If rhabdomyolysis is diagnosed, or even suspected, pregabalin should be withdrawn. Abrupt discontinuation can cause insomnia, nausea, headache, diarrhea, and other symptoms that suggest physical dependence. To avoid withdrawal symptoms, pregabalin should be discontinued slowly, over 1 week or more. Reproductive Toxicity. Pregabalin has adverse effects on reproduction and fetal development when taken by females or males. When given to pregnant female rats and rabbits, pregabalin caused fetal growth delay, fetal death, structural abnormalities (eg, skeletal and visceral malformation), and impaired function of the nervous system and reproductive system. Data on human reproduction are lacking. At this time, pregabalin is classified in FDA Pregnancy Risk Category C: Animal studies show a risk of fetal harm, but no controlled studies in women have been done. When given to male rats before and during mating with untreated females, pregabalin decreased sperm counts and motility, decreased fertility, reduced fetal weight, and caused fetal abnormalities. Men using the drug should be informed about the possibility of decreased fertility and male-mediated teratogenicity. Use in Breast-feeding. We do not know with certainty whether pregabalin is excreted in breast milk. Until additional data are available, it is best for the patient to either stop nursing or stop taking pregabalin unless it is determined that the benefits of breast-feeding outweigh the risks of pregabalin exposure to the infant. Drug Interactions. Alcohol, opioids, benzodiazepines, and other CNS depressants may intensify the depressant effects of pregabalin. Accordingly, such combinations should be avoided. When pregabalin is discontinued, dosage should be gradually tapered, over 1 week or longer.

Hydrocortisone

Ther. Class. anti-inflammatories (steroidal) Pharm. Class. corticosteroids Indications Management of inflammation and pruritis associated with various allergic/immunologic skin problems. Action Suppress normal immune response and inflammation. Therapeutic Effects: Suppression of dermatologic inflammation and immune processes.

Nitroglycerin (Nitrostat)

Ther. Class. antianginals Pharm. Class. nitrates Indications • Acute (translingual, SL, ointment) and long-term prophylatic (oral, transdermal) management of angina pectoris. • PO: Adjunct treatment of HF. • IV: Adjunct treatment of acute MI. • Production of controlled hypotension during surgical procedures. • Treatment of HF. Action • Increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions. • Produces vasodilation (venous greater than arterial). • Decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume (preload). • Reduces myocardial oxygen consumption. Therapeutic Effects: • Relief or prevention of anginal attacks. • Increased cardiac output. • Reduction of BP. Adverse Reactions/Side Effects* CNS: dizziness, headache, apprehension, restlessness, weakness. EENT: blurred vision. CV: hypotension, tachycardia, syncope. GI: abdominal pain, nausea, vomiting. Derm: contact dermatitis (transdermal). Misc: alcohol intoxication (large IV doses only), cross-tolerance, flushing, tolerance.

Rivaroxaban (Xarelto)

Ther. Class. anticoagulants Pharm. Class. antithrombotics factor xa inhibitors Indications • Prevention of deep vein thrombosis that may lead to pulmonary embolism following knee or hip replacement surgery. • Reduction in risk of stroke/systemic embolism in patients with nonvalvular atrial fibrillation. • Treatment of and reduction in risk of recurrence of deep vein thrombosis or pulmonary embolism. Action Acts as selective factor X inhibitor that blocks the active site of factor Xa, inactivating the cascade of coagulation. Therapeutic Effects: Prevention of thromboembolic events. selective inhibition of factor Xa (activated factor X). binds directly with the active center of factor Xa, and thereby inhibits production of thrombin. Compared with warfarin, our oldest oral anticoagulant, rivaroxaban has several advantages: rapid onset, fixed dosage, lower bleeding risk, few drug interactions, and no need for INR monitoring. Rivaroxaban has three approved uses: (1) prevention of DVT and PE following total hip or knee replacement surgery, (2) prevention of stroke in patients with atrial fibrillation, and (3) treatment of DVT and PE unrelated to orthopedic surgery. Patients who received rivaroxaban (10 mg once daily) were much less likely to experience DVT, VTE, PE, or death, compared with patients who received enoxaparin (40 mg once daily or 30 mg twice daily). With both drugs, the incidence of major bleeding episodes was low (0.2%). Rivaroxaban was at least as effective as warfarin, and carried the same risk of major hemorrhagic events of all kinds—but had a lower risk for intracranial bleeds and fatal bleeds. Pharmacokinetics Rivaroxaban is administered orally. Rivaroxaban is eliminated in the urine (36% as unchanged drug) and feces (7% as unchanged drug), with a half-life of 5 to 9 hours. In patients with renal impairment or hepatic impairment, rivaroxaban levels may accumulate. Adverse Effects Bleeding. Bleeding is the most common adverse effect, and can occur at any site. Patients have experienced epidural hematoma, as well as major intracranial, retinal, adrenal, and GI bleeds. Some people have died. Bleeding risk is increased by other drugs that impede hemostasis. How does rivaroxaban compare with warfarin? The risk of hemorrhagic stroke and other major bleeds is significantly lower with rivaroxaban. In the event of overdose, we have no specific antidote to reverse this drug's anticoagulant effects. However we can prevent further absorption of ingested rivaroxaban with activated charcoal. Treatment with several agents—recombinant factor VIIa, prothrombin complex concentrate (PCC), or activated PCC—can be considered. Preliminary studies of PCC have been promising, but more testing must be completed. Because rivaroxaban is highly protein bound, dialysis is unlikely to remove it from the blood. Spinal/Epidural Hematoma. Like all other anticoagulants, rivaroxaban poses a risk of spinal or epidural hematoma in patients undergoing spinal puncture or epidural anesthesia. Prolonged or permanent paralysis can result. Rivaroxaban should be discontinued at least 18 hours before removing an epidural catheter; once the catheter is out, another 6 hours should elapse before rivaroxaban is restarted. If a traumatic puncture occurs, rivaroxaban should be delayed for at least 24 hours. Anticoagulant-related spinal/epidural hematoma is discussed further above (see Adverse Effects under Heparin). Drug Interactions Owing to the risk of bleeding, rivaroxaban should not be combined with other anticoagulants. Concurrent use with antiplatelet drugs and fibrinolytics should be done with caution. Precautions Renal Impairment. Renal impairment can delay excretion of rivaroxaban, and can thereby increase the risk of bleeding. Accordingly, rivaroxaban should be avoided in patients with severe renal impairment, indicated by a CrCl below 30 mL/min. In patients with moderate renal impairment (CrCl 30 to 50 mL/min), rivaroxaban should be used with caution. If renal failure develops during treatment, rivaroxaban should be discontinued. Hepatic Impairment. In clinical trials, rivaroxaban levels and anticoagulation were excessive in patients with moderate hepatic impairment. Accordingly, in patients with moderate or severe hepatic impairment, rivaroxaban should not be used. Pregnancy. Rivaroxaban appears unsafe in pregnancy. Rivaroxaban is classified in FDA Pregnancy Risk Category C, and should be used only if the benefits are deemed to outweigh the risks to the mother and fetus.

Acetazolamide (Diamox)

Ther. Class. anticonvulsants antiglaucoma agents diuretics ocular hypotensive agent Pharm. Class. carbonic anhydrase inhibitors Indications • Lowering of intraocular pressure in the treatment of glaucoma. • Management of acute altitude sickness. • Edema due to HF. • Adjunct to the treatment of refractory seizures. Unlabeled Use(s): • Reduce cerebrospinal fluid production in hydrocephalus. • Prevention of renal calculi composed of uric acid or cystine. Action • Inhibition of carbonic anhydrase in the eye results in decreased secretion of aqueous humor. • Inhibition of renal carbonic anhydrase, resulting in self-limiting urinary excretion of sodium, potassium, bicarbonate, and water. • CNS inhibition of carbonic anhydrase and resultant diuresis may abnormal neuronal firing. • Alkaline diuresis prevents precipitation of uric acid or cystine in the urinary tract. Therapeutic Effects: • Lowering of intraocular pressure. • Control of some types of seizures. • Prevention and treatment of acute altitude sickness. • Diuresis and subsequent mobilization of excess fluid. • Prevention of uric acid or cystine renal calculi. Adverse Reactions/Side Effects* CNS: depression, fatigue, weakness, drowsiness. EENT: transient nearsightedness. GI: anorexia, metallic taste, nausea, vomiting, melena. GU: crystalluria, renal calculi. Derm: STEVENS-JOHNSON SYNDROME, rashes. Endo: hyperglycemia. F and E: hyperchloremic acidosis, hypokalemia, growth retardation (in children receiving chronic therapy). Hemat: APLASTIC ANEMIA, HEMOLYTIC ANEMIA, LEUKOPENIA. Metab: weight loss, hyperuricemia. Neuro: paresthesias. Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS. Drug-Drug: • Excretion of barbiturates, aspirin, and lithium is and may lead to effectiveness. • Excretion of amphetamine, quinidine, procainamide, and possibly tricyclic antidepressants is and may lead to toxicity. • May cyclosporine levels.

Trazodone (Desyrel)

Ther. Class. antidepressants Indications • Major depression. Unlabeled Use(s): Insomnia, chronic pain syndromes, including diabetic neuropathy, and anxiety. Action Alters the effects of serotonin in the CNS. Therapeutic Effects: Antidepressant action, which may develop only over several weeks. Adverse Reactions/Side Effects* CNS: SUICIDAL THOUGHTS, drowsiness, confusion, dizziness, fatigue, hallucinations, headache, insomnia, nightmares, slurred speech, syncope, weakness. EENT: blurred vision, tinnitus. CV: hypotension, arrhythmias, chest pain, hypertension, palpitations, QT interval prolongation, tachycardia. GI: dry mouth, altered taste, constipation, diarrhea, excess salivation, flatulence, nausea, vomiting. GU: hematuria, erectile dysfunction, priapism, urinary frequency. Derm: rash. Hemat: anemia, leukopenia. MS: myalgia. Neuro: tremor. Nursing Implications Assessment • Monitor BP and pulse rate before and during initial therapy. Monitor ECGs in patients with pre-existing cardiac disease before and periodically during therapy to detect arrhythmias. • Assess for possible sexual dysfunction. • Assess for serotonin syndrome (mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile BP, hyperthermia], neuromuscular aberrations [hyper-reflexia, incoordination], and/or GI symptoms [nausea, vomiting, diarrhea]), especially in patients taking other serotonergic drugs (SSRIs, SNRIs, triptans). Depression: • Assess mental status (orientation, mood, and behavior) frequently. • Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults ≤24 yr. After starting therapy, children, adolescents, and young adults should be seen by health care professional at least weekly for 4 wk, every 3 wk for next 4 wk, and on advice of health care professional thereafter. Pain: • Assess location, duration, intensity, and characteristics of pain before and periodically during therapy. Use pain scale to assess effectiveness of medicine. Lab Test Considerations: Assess CBC and renal and hepatic function before and periodically during therapy. Slight, clinically insignificant in leukocyte and neutrophil counts may occur.

Bupropion (Wellbutrin)

Ther. Class. antidepressants smoking deterrents Pharm. Class. aminoketones Indications • Treatment of depression (with psychotherapy). • Depression with seasonal affective disorder (Aplenzin and Wellbutrin XL only). • Smoking cessation (Zyban only). Unlabeled Use(s): • Treatment of ADHD in adults (SR only). • To increase sexual desire in women. Action • Decreases neuronal reuptake of dopamine in the CNS. • Diminished neuronal uptake of serotonin and norepinephrine (less than tricyclic antidepressants). Therapeutic Effects: • Diminished depression. • Decreased craving for cigarettes. Although well absorbed, rapidly and extensively metabolized by the liver. Adverse Reactions/Side Effects* CNS: HOMICIDAL THOUGHTS/BEHAVIOR, SEIZURES, SUICIDAL THOUGHTS/BEHAVIOR, agitation, headache, aggression, anxiety, delusions, depression, hallucinations, hostility, insomnia, mania, panic, paranoia, psychoses. CV: hypertension. GI: dry mouth, nausea, vomiting, change in appetite, weight gain, weight loss. Derm: photosensitivity. Endo: hyperglycemia, hypoglycemia, syndrome of inappropriate ADH secretion. Neuro: tremor. May require 4 wk or longer for full effects. Actions and Uses. Bupropion [Wellbutrin, Budeprion, Aplenzin] is a unique antidepressant similar in structure to amphetamine. Like amphetamine, bupropion has stimulant actions and suppresses appetite. Antidepressant effects begin in 1 to 3 weeks. The mechanism by which depressions relieved is unclear, but may be related to blockade of dopamine and/or NE reuptake. The drug does not affect serotonergic, cholinergic, or histaminergic transmission, and does not inhibit MAO. In contrast to SSRIs, bupropion does not cause weight gain or sexual dysfunction. In fact, it appears to increase sexual desire and pleasure, so bupropion has been used to counteract sexual dysfunction in patients taking SSRIs and heighten sexual interest in women with hypoactive sexual desire disorder. Because of its efficacy and side effect profile, bupropion is a good alternative to SSRIs for patients who cannot tolerate SSRIs. Bupropion has two antidepressant indications: (1) major depressive disorder and (2) prevention of seasonal affective disorder (SAD). In addition to its use in depression, bupropion, marketed as Zyban and Buproban, is approved as an aid to quit smoking. Unlabeled uses include relief of neuropathic pain, treatment of depressive episodes in bipolar disorder, and management of attention-deficit/hyperactivity disorder. Pharmacokinetics. Bupropion is administered orally. With the IR tablets, plasma levels peak about 2 hours after dosing. Bioavailability is low: In animals, only 5% to 20% of each dose reaches the systemic circulation. Bupropion undergoes extensive hepatic metabolism, primarily by CYP2B6. The elimination half-life ranges from 8 to 24 hours. Adverse Effects. Bupropion is generally well tolerated, but can cause seizures. The most common adverse effects are agitation, headache, dry mouth, constipation, weight loss, GI upset, dizziness, tremor, insomnia, blurred vision, and tachycardia. In addition, bupropion carries a small risk of causing psychotic symptoms, including hallucinations and delusions. Accordingly, the drug should not be used in patients with psychotic disorders. Like other antidepressants, bupropion may increase the risk of suicide in children, adolescents, and young adults. In contrast to many other antidepressants, bupropion does not cause adverse sexual effects. Seizures are the side effect of greatest concern. MAOIs can increase the risk of bupropion toxicity. Accordingly, patients should discontinue MAOIs at least 2 weeks before starting bupropion.

Ondansertron (Zofran)

Ther. Class. antiemetics Pharm. Class. 5-HT3 agonists Indications • Prevention of nausea and vomiting associated with highly or moderately emetogenic chemotherapy. • PO: Prevention of nausea and vomiting associated with radiation therapy. • Prevention and treatment of postoperative nausea and vomiting. Action Blocks the effects of serotonin at 5-HT3-receptor sites (selective antagonist) located in vagal nerve terminals and the chemoreceptor trigger zone in the CNS. Therapeutic Effects: Decreased incidence and severity of nausea and vomiting following chemotherapy or surgery. Adverse Reactions/Side Effects* CNS: SEROTONIN SYNDROME, headache, dizziness, drowsiness, fatigue, weakness. CV: TORSADE DE POINTES, QT interval prolongation. GI: constipation, diarrhea, abdominal pain, dry mouth, liver enzymes. Neuro: extrapyramidal reactions. Derm: STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS.

Promethazine (Phenergan)

Ther. Class. antiemetics antihistamines sedative hypnotics Pharm. Class. phenothiazines Promethazine [Phenergan, Phenadoz] is the most widely used antiemetic in young children, despite its adverse side effects (respiratory depression and local tissue injury), and despite the availability of potentially safer alternatives (eg, ondansetron). Promethazine can cause severe respiratory depression, especially in very young patients. Deaths have occurred. Accordingly, the drug is now contraindicated for use in children younger than 2 years and should be used with caution in children older than 2 years. Indications • Treatment of various allergic conditions and motion sickness. • Preoperative sedation. • Treatment and prevention of nausea and vomiting. • Adjunct to anesthesia and analgesia. Action • Blocks the effects of histamine. • Has inhibitory effect on the chemoreceptor trigger zone in the medulla, resulting in antiemetic properties. • Alters the effects of dopamine in the CNS. • Possesses significant anticholinergic activity. • Produces CNS depression by indirectly decreased stimulation of the CNS reticular system. Therapeutic Effects: • Relief of symptoms of histamine excess usually seen in allergic conditions. • Diminished nausea or vomiting. • Sedation. Adverse Reactions/Side Effects* CNS: NEUROLEPTIC MALIGNANT SYNDROME, confusion, disorientation, sedation, dizziness, extrapyramidal reactions, fatigue, insomnia, nervousness. EENT: blurred vision, diplopia, tinnitus. CV: bradycardia, hypertension, hypotension, tachycardia. GI: constipation, drug-induced hepatitis, dry mouth. Derm: photosensitivity, severe tissue necrosis upon infiltration at IV site, rashes. Hemat: blood dyscrasias. Interactions Drug-Drug: • Additive CNS depression with other CNS depressants, including alcohol, other antihistamines, opioid analgesics, and other sedative/hypnotics. • Neuroleptic malignant syndrome can occur when used concurrently with antipsychotics. • Additive anticholinergic effects with other drugs possessing anticholinergic properties, including other antihistamines, antidepressants, atropine, haloperidol, other phenothiazines, quinidine, and disopyramide. • May precipitate seizures when used with drugs that lower seizure threshold. • Concurrent use with MAO inhibitors may result in sedation and anticholinergic side effects.

Miconazole (Micatin)

Ther. Class. antifungals (topical) Indications Treatment of a variety of cutaneous fungal infections, including tinea pedis (athlete's foot), tinea cruris (jock itch), tinea corporis (ringworm). Action Affects the synthesis of the fungal cell wall, allowing leakage of cellular contents. Therapeutic Effects: Decrease in symptoms of fungal infection. Evaluation/Desired Outcomes Decrease in skin irritation and resolution of infection. Early relief of symptoms may be seen in 2-3 days. For tinea cruris and tinea corporis, 2 wk are needed, and for tinea pedis, therapeutic response may take 3-4 wk. Recurrent fungal infections may be a sign of systemic illness.

Loratadine (Claritin)

Ther. Class. antihistamines Indications • Relief of symptoms of seasonal allergies. • Management of chronic idiopathic urticaria. • Management of hives. Action Blocks peripheral effects of histamine released during allergic reactions. Therapeutic Effects: Decreased symptoms of allergic reactions (nasal stuffiness; red, swollen eyes, itching). Contraindications/Precautions Contraindicated in: Hypersensitivity. Use Cautiously in: • Hepatic impairment or CCr <30 mL/min ( dose to 10 mg every other day); • Lactation: Usually compatible with breast feeding (AAP); • OB: Pedi: Pregnancy or children <2 yr (safety not established). Syrup contains sodium benzoate, avoid use in neonates; • Geri: risk of adverse reactions. Adverse Reactions/Side Effects* CNS: confusion, drowsiness (rare), paradoxical excitation. EENT: blurred vision. GI: dry mouth, GI upset. Derm: photosensitivity, rash. Metab: weight gain. Interactions Drug-Drug: • The following interactions may occur, but are less likely to occur with loratidine than with more sedating antihistamines. • MAO inhibitors may intensify and prolong effects of antihistamines. • CNS depression may occur with other CNS depressants, including alcohol, antidepressants, opioid analgesics, and sedative/hypnotics. • Amiodarone may loratadine levels and risk of QTc interval prolongation. Drug-Natural Products: Kava-kava, valerian, or chamomile can CNS depression.

Amlodipine (Norvasc)

Ther. Class. antihypertensives Pharm. Class. renin inhibitors calcium channel blockers Contraindicated in: • Severe renal impairment; • OB: Pregnancy (can cause fetal/neonatal morbidity and death). Use Cautiously in: • Severe hepatic impairment (titrate carefully); • OB: Women with child-bearing potential. SE: CNS: headache, dizziness, fatigue. CV: peripheral edema, angina, bradycardia, hypotension, palpitations. GI: gingival hyperplasia, nausea. Derm: flushing. Amlodipine—. Additive hypotension may occur when used concurrently with fentanyl, other antihypertensives, nitrates, acute ingestion of alcohol, or quinidine. • Antihypertensive effects may be by concurrent use of nonsteroidal anti-inflammatory agents. • May risk of neurotoxicity with lithium. Drug-Food: • Amlodipine—. Grapefruit juice serum levels and effect. Evaluation/Desired Outcomes Decrease in BP. Effect is largely attained within 1-2 wks.

Ibuprofen (Advil, Motrin)

Ther. Class. antipyretics antirheumatics nonopioid analgesics nonsteroidal anti-inflammatory agents Pharm. Class. nonopioid analgesics Action Inhibits prostaglandin synthesis. Therapeutic Effects: • Decreased pain and inflammation. • Reduction of fever. Mostly metabolized by the liver; small amounts (1%) excreted unchanged by the kidneys. Exercise Extreme Caution in: History of GI bleeding or GI ulcer disease. Adverse Reactions/Side Effects* CNS: headache, dizziness, drowsiness, intraventricular hemorrhage (ibuprofen lysine), psychic disturbances. EENT: amblyopia, blurred vision, tinnitus. CV: HF, MYOCARDIAL INFARCTION, STROKE, arrhythmias, edema, hypertension. F and E: hyperkalemia. GI: GI BLEEDING, HEPATITIS, constipation, dyspepsia, nausea, necrotizing enterocolitis (ibuprofen lysine), vomiting, abdominal discomfort. GU: cystitis, hematuria, renal failure. Derm: EXFOLIATIVE DERMATITIS, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, rash, injection site reaction. Hemat: anemia, blood dyscrasias, prolonged bleeding time. Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS.

Bumetanide (Bumex)

Ther. Class. diuretics Pharm. Class. loop diuretics Indications • Edema due to heart failure, hepatic disease, or renal impairment. Unlabeled Use(s): Reversal of oliguria in preterm neonates. Action • Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. • Increases renal excretion of water, sodium chloride, magnesium, potassium, and calcium. • Effectiveness persists in impaired renal function. Therapeutic Effects: Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions). Pharmacokinetics Absorbtion: Well absorbed after oral or IM administration. Distribution: Widely distributed. Protein Binding: 72-96%. Metabolism and Excretion: Partially metabolized by liver; 50% eliminated unchanged by kidneys and 20% excreted in feces. Half-life: 60-90 min (6 hr in neonates). Adverse Reactions/Side Effects* CNS: dizziness, encephalopathy, headache. EENT: hearing loss, tinnitus. CV: hypotension. GI: diarrhea, dry mouth, nausea, vomiting. GU: BUN, excessive urination. Derm: STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, photosensitivity, pruritis, rash. Endo: hyperglycemia, hyperuricemia. F and E: dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis. MS: arthralgia, muscle cramps, myalgia.

Spironolactone (Aldactone)

Ther. Class. diuretics potassium-sparing diuretics Indications • Management of primary hyperaldosteronism. • Management of edema associated with HF, cirrhosis and nephrotic syndrome. • Management of essential hypertension. • Treatment of hypokalemia (counteracts potassium loss caused by other diuretics). Action Causes loss of sodium bicarbonate and calcium while saving potassium and hydrogen ions by antagonizing aldosterone. Therapeutic Effects: • Increased survival in patients with severe heart failure (New York Heart Association class II-IV). • Weak diuretic and antihypertensive response when compared with other diuretics. • Conservation of potassium. Hypertension and Edema. Spironolactone is used primarily for hypertension and edema. Although it can be employed alone, the drug is used most commonly in combination with a thiazide or loop diuretic. The purpose of spironolactone in these combinations is to counteract the potassium-wasting effects of the more powerful diuretics. Spironolactone also makes a small contribution to diuresis. Heart Failure. In patients with severe heart failure, spironolactone reduces mortality and hospital admissions. Benefits derive from protective effects of aldosterone blockade in the heart and blood vessels. Other Uses. spironolactone can by used for primary hyperaldosteronism, premenstrual syndrome, polycystic ovary syndrome, and acne in young women. Adverse Effects Hyperkalemia. The potassium-sparing effects of spironolactone can result in hyperkalemia, a condition that can produce fatal dysrhythmias. Although hyperkalemia is most likely when spironolactone is used alone, it can also develop when spironolactone is used in conjunction with potassium wasting agents (thiazides and loop diuretics). If serum potassium rises above 5 mEq/L, or if signs of hyperkalemia develop (eg, abnormal heart rhythm), spironolactone should be discontinued and potassium intake restricted. Injection of insulin can help lower potassium levels by promoting potassium uptake into cells. Endocrine Effects. Spironolactone is a steroid derivative with a structure similar to that of steroid hormones (eg, progesterone, estradiol, testosterone). As a result, spironolactone can cause a variety of endocrine effects, including gynecomastia, menstrual irregularities, impotence, hirsutism, and deepening of the voice. Benign and Malignant Tumors. When given long term to rats in doses 25 to 250 times those used in humans, spironolactone has caused benign adenomas of the thyroid and testes, malignant mammary tumors, and proliferative changes in the liver. The risk of tumors in humans from use of normal doses is unknown.

Bisacodyl (Dulcolax)

Ther. Class. laxatives Pharm. Class. stimulant laxatives Indications • Treatment of constipation. • Evacuation of the bowel before radiologic studies or surgery. • Part of a bowel regimen in spinal cord injury patients. Action • Stimulates peristalsis. • Alters fluid and electrolyte transport, producing fluid accumulation in the colon. Therapeutic Effects: Evacuation of the colon. Adverse Reactions/Side Effects* GI: abdominal cramps, nausea, diarrhea, rectal burning. F and E: hypokalemia (with chronic use). MS: muscle weakness (with chronic use). Misc: protein-losing enteropathy, tetany (with chronic use).

Docusate sodium (Colace) Senna (Senokot)

Ther. Class. laxatives Pharm. Class. stool softeners Indications • PO: Prevention of constipation (in patients who should avoid straining, such as after MI or rectal surgery). • Rect: Used as enema to soften fecal impaction. Action • Promotes incorporation of water into stool, resulting in softer fecal mass. • May also promote electrolyte and water secretion into the colon. Therapeutic Effects: Softening and passage of stool. Adverse Reactions/Side Effects* EENT: throat irritation. GI: mild cramps, diarrhea. Derm: rashes.

Cyclobenzaprine (Flexeril)

Ther. Class. skeletal muscle relaxants (centrally acting) Indications • Management of acute painful musculoskeletal conditions associated with muscle spasm. Unlabeled Use(s): Management of fibromyalgia. Action Reduces tonic somatic muscle activity at the level of the brainstem. Structurally similar to tricyclic antidepressants. Therapeutic Effects: Reduction in muscle spasm and hyperactivity without loss of function. Adverse Reactions/Side Effects* CNS: dizziness, drowsiness, confusion, fatigue, headache, nervousness. EENT: dry mouth, blurred vision. CV: arrhythmias. GI: constipation, dyspepsia, nausea, unpleasant taste. GU: urinary retention.

Cholecalciferol (Vitamin D3)

Ther. Class. vitamins Pharm. Class. fat-soluble vitamins Indications Treatment or prevention of vitamin D deficiency. Action • Requires activation in the liver and kidneys to create the active form of vitamin D3 (calcitriol). • Promotes the intestinal absorption of dietary calcium. Therapeutic Effects: Treatment and prevention of deficiency states, particularly bone manifestations. Adverse Reactions/Side Effects* Seen primarily as manifestations of toxicity (hypercalcemia) CNS: headache, irritability, somnolence, weakness. EENT: conjunctivitis, photophobia. CV: arrhythmias, hypertension. GI: anorexia, constipation, dry mouth, liver enzymes, metallic taste, nausea, PANCREATITIS, polydipsia, vomiting, weight loss. GU: albuminuria, azotemia, polyuria. Derm: pruritus. F and E: hypercalcemia. MS: bone pain, muscle pain.

Guaifenesin and Dextromethorphan (Robitussin DM)

This combination medication is used to relieve coughs caused by the common cold, bronchitis, and other breathing illnesses. Guaifenesin belongs to a class of drugs known as expectorants. It works by thinning and loosening mucus in the airways, clearing congestion, and making breathing easier. Dextromethorphan belongs to a class of drugs known as cough suppressants. It acts on a part of the brain (cough center) to reduce the urge to cough.

petrolatum (Aquaphor)

This medication is used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations (e.g., diaper rash, skin burns from radiation therapy). Emollients are substances that soften and moisturize the skin and decrease itching and flaking. Some products (e.g., zinc oxide, white petrolatum) are used mostly to protect the skin against irritation (e.g., from wetness). Dry skin is caused by a loss of water in the upper layer of the skin. Emollients/moisturizers work by forming an oily layer on the top of the skin that traps water in the skin. Petrolatum, lanolin, mineral oil and dimethicone are common emollients. Humectants, including glycerin, lecithin, and propylene glycol, draw water into the outer layer of skin. Many products also have ingredients that soften the horny substance (keratin) that holds the top layer of skin cells together (e.g., urea, alpha hydroxy acids such as lactic/citric/glycolic acid, and allantoin). This helps the dead skin cells fall off, helps the skin keep in more water, and leaves the skin feeling smoother and softer.

Carboxymethylcellulose (Refresh Celluvisc, Theratears) 1% ophalmic gel

This medication is used to relieve dry, irritated eyes. Common causes for dry eyes include wind, sun, heating/air conditioning, computer use/reading, and certain medications. Eye lubricants keep the eye moist, help to protect the eye from injury and infection, and decrease symptoms of dry eyes such as burning, itching, and feeling as if something is in the eye.

Clonazepam (Klonopin)

Trade Name(s) • KlonoPIN • Rivotril Classification(s) Ther. Class. anticonvulsants Pharm. Class. benzodiazepines Controlled Substance Schedule: IV Indications • Treatment of Lennox-Gastaut, akinetic, or myoclonic seizures. • Panic disorder with or without agoraphobia. Unlabeled Use(s): • Uncontrolled leg movements during sleep. • Neuralgias. • Infantile spasms. • Sedation. • Adjunct management of acute mania, acute psychosis, or insomnia. Action • Anticonvulsant effects may be due to presynaptic inhibition. • Produces sedative effects in the CNS, probably by stimulating inhibitory GABA receptors. Therapeutic Effects: • Prevention of seizures. • Decreased manifestations of panic disorder. Mostly metabolized by the liver. Adverse Reactions/Side Effects* CNS: SUICIDAL THOUGHTS, behavioral changes, drowsiness, fatigue, slurred speech, ataxia, sedation, abnormal eye movements, diplopia, nystagmus. Resp: secretions. CV: palpitations. Derm: rash. GI: constipation, diarrhea, hepatitis, weight gain. GU: dysuria, nocturia, urinary retention. Hemat: anemia, eosinophilia, leukopenia, thrombocytopenia. Neuro: ataxia, hypotonia. Misc: fever, physical dependence, psychological dependence, tolerance.

Fibromyalgia

a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Researchers believe that fibromyalgia amplifies painful sensations by affecting the way your brain processes pain signals. Women are more likely to develop fibromyalgia than are men. Many people who have fibromyalgia also have tension headaches, temporomandibular joint (TMJ) disorders, irritable bowel syndrome, anxiety and depression. While there is no cure for fibromyalgia, a variety of medications can help control symptoms. Exercise, relaxation and stress-reduction measures also may help.

Serotonin Syndrome

a group of symptoms that may occur following use of certain serotonergic medications or drugs.[1] The degree of symptoms can range from mild to severe.[2] Symptoms include high body temperature, agitation, increased reflexes, tremor, sweating, dilated pupils, and diarrhea.[1][2] Body temperature can increase to greater than 41.1 °C (106.0 °F).[2] Complications may include seizures and extensive muscle breakdown.

Calcium rich foods

almond (milk/nuts) calcium fortified foods canned salmon/sardines cheese cream soups (with milk) greens: collard/ mustard/turnip kale milk soy (beans/milk) spinach tofu yogurt

Olanzapine (Zyprexa)

an SGA (Second Generation Antipsycotics) approved for (1) schizophrenia, (2) maintenance therapy of bipolar disorder, (3) acute agitation associated with schizophrenia and bipolar mania, and (4) treatment-resistant major depression (in combination with fluoxetine). In addition, olanzapine is used offlabel to suppress nausea and vomiting in cancer patients. The drug is similar to clozapine in structure and actions, but carries little or no risk of agranulocytosis (although it can cause leukopenia/neutropenia). The risk of metabolic effects is higher than with most other SGAs. Mechanism of Action. Olanzapine blocks receptors for serotonin, dopamine, histamine, acetylcholine, and norepinephrine. Therapeutic effects are believed to result from blocking 5-HT2 and D2 receptors. Adverse effects result in part from blocking receptors for histamine, acetylcholine, and norepinephrine. Pharmacokinetics. Olanzapine is well absorbed following oral administration. Food does not alter the rate or extent of absorption. Plasma levels peak 6 hours after dosing and decline with a half-life of 30 hours. Hepatic metabolism is extensive. Therapeutic Uses: Schizophrenia. In patients with schizophrenia, olanzapine is at least as effective as haloperidol or risperidone and produces fewer EPS (Extrapyramidal symptoms) than either drug. Comparative trials with clozapine reveal that olanzapine is not inferior to clozapine in patients previously refractory to treatment. Interestingly, olanzapine can relieve psychosis induced by drugs taken for PD, without reversing antiparkinsonism effects. Bipolar Disorder. Olanzapine is approved for monotherapy of acute mania in patients with bipolar disorder. Benefits appear equal to those of lithium, a drug of choice for this condition. Adverse Effects with Oral Olanzapine. Regarding serious adverse effects, olanzapine is a mixed blessing: The drug carries a low risk of EPS but carries a high risk of metabolic effects. Acute EPS are minimal when olanzapine is used at the recommended dosage. Among the SGAs, olanzapine (along with clozapine) poses the highest risk of serious metabolic effects: weight gain, diabetes, and dyslipidemia—all of which can lead to adverse cardiovascular events and premature death. Like all other antipsychotic drugs, olanzapine can increase mortality in older-adult patients with dementia related psychosis. Olanzapine can cause leukopenia/neutropenia, and can thereby increase the risk of infection. Accordingly, for patients at high risk—including those with preexisting low WBC counts and those with a history of drug-induced leukopenia/neutropenia—complete blood counts should be conducted often during the first few months of treatment. If the ANC falls below 1000/mm3, olanzapine should be discontinued, and the patient should be monitored for fever and other signs of infection. Neutrophil counts should be monitored until they return to normal. Mild effects are relatively common. Olanzapine causes somnolence (alternatively "sleepiness" or "drowsiness") in 26% of patients, presumably by blocking H1 receptors. Blockade of muscarinic receptors causes constipation and other anticholinergic effects. Alpha1- adrenergic blockade causes orthostatic hypotension. Following an overdose, the signs and symptoms may include slurred speech, ataxia, nystagmus, hypotension, respiratory depression, and drowsiness. Adverse Effects with Long-Acting IM Olanzapine. Overdose with the long-acting IM depot preparation of olanzapine [Zyprexa Relprevv] is dangerous. Principal concerns are CNS depression (ranging from mild sedation to coma) and/or delirium (confusion, disorientation, agitation, anxiety). Patients may also experience EPS, joint pain, ataxia, aggression, dizziness, weakness, hypertension, and convulsions. Symptoms typically develop within 1 to 3 hours of dosing, but may also develop later. After the injection, patients should be observed by a healthcare provider for at least 3 hours, and should be warned against driving and other hazardous activities for the remainder of the day.

Hydroxyzine Pamoate (Vistaril)

an antihistamine, promotes drowsiness and reduces anxiety. Hydroxyzine can be useful for nausea and vomiting as well as insomnia. Although widely believed to enhance analgesia, proof is lacking. Drawbacks include worsening of constipation, urinary retention, and cognitive impairment.

Rifaximin (Xifaxan)

antibiotic

Tiotropium (Spiriva)

anticholinergic bronchodilator

Potassium rich foods

artichoke avocados bananas cantaloupe cassava dried fruits grapefruit honey dew jack fruit kiwi kohlrabi lima beans mango meats milk dried peas and beans nuts oranges/orange juice papaya peaches pears plantains pomegranate potatoes (white and sweet) prunes/prune juice pumpkin rhubarb salt substitute spinach sunflower seeds Swiss chard tomatoes/tomato juice vegetable juice winter squash

Vitamin K rich foods

asparagus beet greens broccoli brussel sprouts cabbage collard greens dandelion leaves garden cress green tea leaves kale mustard greens parsley spinach swiss chard turnip greens

Low sodium foods

baked or broiled poultry canned pumpkin cooked turnips egg yolk fresh vegetables fruit grits (not instant) honey jams and jellies lean meats low-calorie mayonnaise macaroons potatoes puffed wheat and rice red kidney and lima beans sherbet unsalted nuts whiskey

Sodium rich foods

baking mixes (pancakes, muffins) barbecue sauce buttermilk butter/margarine canned chili canned seafood canned soups canned spaghetti sauce cured meats dry onion soup mix "fast" foods frozen dinners macaroni and cheese microwave dinners Parmesan cheese pickles potato salad pretzels, potato chips salad dressings (prepared) salt sauerkraut tomato ketchup

verapamil

calcium channel blocker

Vitamin D rich foods

canned salmon, sardines, tuna cereals fish fish liver oils fortified milk nonfat dry milk

Iron-rich foods

cereals clams dried beans and peas dried fruit leafy green vegetables lean red meats molasses (blackstrap) organ meats

Divalproex (Depakote)

employed first for epilepsy and later for bipolar disorder (manicdepressive illness), is now approved for prophylaxis of migraine too. The drug is a form of valproic acid. Divalproex reduces the incidence of attacks by 50% or more in 30% to 50% of patients. However, when attacks do occur, their intensity and duration are not diminished. In migraineurs, the most common side effect is nausea. Other side effects include fatigue, weight gain, tremor, bone loss, and reversible hair loss. Potentially fatal pancreatitis and hepatitis occur rarely. Divalproex can cause neural tube defects in the developing fetus, and hence is contraindicated during pregnancy. The drug is available in delayed-release and extended-release tablets. The dosage range is 500 to 1000 mg/day.

Oxcarbazepine (Trileptal)

epileptic seizure trigeminal neuralgia bipolar

EPS

extrapyramidal symptoms AKA extrapyramidal side effects (EPSE), are drug-induced movement disorders that include acute and tardive symptoms. These symptoms include dystonia (continuous spasms and muscle contractions), akathisia (motor restlessness), parkinsonism (characteristic symptoms such as rigidity), bradykinesia (slowness of movement), tremor, and tardive dyskinesia (irregular, jerky movements). Antipsychotics are often discontinued due to inefficacy and intolerable side effects such as extrapyramidal symptoms.

Estradiol (Estrace)

hormone replacement

Neuroleptic Malignant Syndrome

is a life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction.

Tolterodine (Detrol)

overactive bladder

positive vs negative symptoms https://www.canadianpharmacyking.com/KingsBlog/uploads/negative-positive-symptoms-schizophrenia.jpg

positive: something added (such as delusions, hallucinations, disorganized speech) negative: something removed (lack of emotion)

Drugs That Reduce Levothyroxine Absorption.

• Histamine2 (H2) receptor blockers (eg, cimetidine [Tagamet]) • Proton pump inhibitors (eg, lansoprazole [Prevacid] • Sucralfate [Carafate] • Cholestyramine [Questran] • Colestipol [Colestid] • Aluminum-containing antacids (eg, Maalox, Mylanta) • Calcium supplements (eg, Tums, Os-Cal) • Iron supplements (eg, ferrous sulfate) • Magnesium salts • Orlistat [Xenical] To ensure adequate absorption of levothyroxine, patients should separate administration of levothyroxine and these drugs by 4 hours. As noted above, food also reduces absorption.