Pharm Exam II

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Antacids

Apo-Cal , BioCal, Calcite-500, Calsan , Cal-Sup, Caltrate , Chooz, Dicarbosil, Equilet, Mallamint, Mega-Cal, Nu-Cal, Os-Cal, Oystercal, Titralac, Tums CALCIUM ACETATE PhosLo CALCIUM CITRATE Citracal CALCIUM PHOSPHATE TRIBASIC (TRICALCIUM PHOSPHATE) Posture Classifications: FLUID AND ELECTROLYTIC BALANCE AGENT; REPLACEMENT SOLUTION; ANTACID Prototype: Calcium gluconate Pregnancy Category: C for calcium acetate; other salts not rated Availability Calcium carbonate: 125 mg, 250 mg, 650 mg, 750 mg, 1.25 g, 1.5 g tablets; Calcium acetate: 667 mg tablets; Calcium citrate: 950 mg, 2376 mg tablets; Calcium phosphate tribasic: 1565.2 mg tablets Actions Rapid-acting antacid with high neutralizing capacity and relatively prolonged duration of action. Decreases gastric acidity, thereby inhibiting proteolytic action of pepsin on gastric mucosa. Also increases lower esophageal sphincter tone. Although classified as a nonsystemic antacid, a slight to moderate alkalosis usually develops with prolonged therapy. Acid rebound, which may follow even low doses, is thought to be caused by release of gastrin triggered by action of calcium in small intestines. Therapeutic Effects Effectively relieves symptoms of acid indigestion and useful as a calcium supplement. Uses Relief of transient symptoms of hyperacidity as in acid indigestion, heartburn, peptic esophagitis, and hiatal hernia. Also used as calcium supplement when calcium intake may be inadequate and in treatment of mild calcium deficiency states. Control of hyperphosphatemia in chronic renal failure (calcium acetate). Unlabeled Uses For treatment of hyperphosphatemia in patients with chronic renal failure and to lower BP in selected patients with hypertension. Contraindications Hypercalcemia and hypercalciuria (e.g., hyperparathyroidism, vitamin D overdosage, decalcifying tumors, bone metastases), calcium loss due to immobilization, severe renal disease, renal calculi, GI hemorrhage or obstruction, dehydration, hypochloremic alkalosis, ventricular fibrillation, cardiac disease, pregnancy (category C). Cautious Use Decreased bowel motility (e.g., with anticholinergics, antidiarrheals, antispasmodics), the older adult, lactation. Route & Dosage All doses are in terms of elemental calcium: 1 g calcium carbonate = 400 mg (20 mEq, 40%) elemental calcium; 1 g calcium acetate = 250 mg (12.6 mEq, 25%) elemental calcium; 1 g calcium citrate = 210 mg (12 mEq, 21%) elemental calcium; 1g tricalcium phosphate = 390 mg (19.3 mEq, 39%) elemental calcium Supplement for Osteoporosis Adult: PO 1-2 g b.i.d. or t.i.d. Antacid Adult: PO 0.5-2 g 4-6 times/d Hyperphosphatemia Adult: PO calcium acetate 2-4 tablets with each meal Administration Oral When used as antacid, give 1 h after meals and at bedtime. When used as calcium supplement, give 1-1 ½ h after meals, unless otherwise directed by physician. Chewable tablet should be chewed well before swallowing or allowed to dissolve completely in mouth, followed with water. Powder form may be mixed with water. Ensure that sustained-release form of drug is not chewed or crushed. It must be swallowed whole. Adverse Effects (1%) GI: Constipation or laxative effect, acid rebound, nausea, eructation, flatulence, vomiting, fecal concretions. Metabolic: Hypercalcemia with alkalosis, metastatic calcinosis, hypercalciuria, hypomagnesemia, hypophosphatemia (when phosphate intake is low). CNS: Mood and mental changes. Urogenital: Polyuria, renal calculi. Interactions Drug: May enhance inotropic and toxic effects of digoxin; magnesium may compete for GI absorption; decreases absorption of TETRACYCLINES, QUINOLONES (ciprofloxacin). Pharmacokinetics Absorption: Approximately 1/3 of dose absorbed from small intestine. Distribution: Crosses placenta. Elimination: Primarily excreted in feces; small amounts excreted in urine, pancreatic juice, saliva, breast milk. Nursing Implications Assessment & Drug Effects Note number and consistency of stools. If constipation is a problem, physician may prescribe alternate or combination therapy with a magnesium antacid or advise patient to take a laxative or stool softener as necessary. Lab tests: Determine serum and urine calcium weekly in patients receiving prolonged therapy and in patients with renal dysfunction. Record amelioration of symptoms of hypocalcemia (see Signs & Symptoms, Appendix F). Observe for S&S of hypercalcemia in patients receiving frequent or high doses, or who have impaired renal function (see Appendix F). Patient & Family Education Do not continue this medication beyond 1-2 wk, since it may cause acid rebound, which generally occurs after repeated use for 1 or 2 wk and leads to chronic use. It is potentially dangerous to self-medicate. Do not take antacids longer than 2 wk without medical supervision. Avoid taking calcium carbonate with cereals or other foods high in oxalates. Oxalates combine with calcium carbonate to form insoluble, nonabsorbable compounds. Do not use calcium carbonate repeatedly with foods high in vitamin D (such as milk) or sodium bicarbonate, as it may cause milk-alkali syndrome: hypercalcemia, distaste for food, headache, confusion, nausea, vomiting, abdominal pain, metabolic alkalosis, hypercalciuria, polyuria, soft tissue calcification (calcinosis), hyperphosphatemia and renal insufficiency. Predisposing factors include renal dysfunction, dehydration, electrolyte imbalance, and hypertension. Do not breast feed while taking this drug without consulting physician

Diazepam

Apo-Diazepam , Diastat, Diazemuls , E-Pam , Meval , Novodipam , Valium, Valrelease, Vivol DIAZEPAM EMULSIFIED Dizac Classifications: CENTRAL NERVOUS SYSTEM AGENT; BENZODIAZEPINE ANTICONVULSANT; ANXIOLYTIC Pregnancy Category: D Controlled Substance: Schedule IV Availability 2 mg, 5 mg, 10 mg tablets; 1 mg/mL, 5 mg/mL, 5 mg/5 mL oral solution; 5 mg/mL injection; 2.5 mg, 5 mg, 10 mg, 15 mg, 20 mg rectal gel Actions Psychotherapeutic agent related to chlordiazepoxide; reportedly superior in antianxiety and anticonvulsant activity, with somewhat shorter duration of action. Like chlordiazepoxide, it appears to act at both limbic and subcortical levels of CNS. Therapeutic Effects Shortens REM and stage 4 sleep but increases total sleep time. Antianxiety and anticonvulsant agent. Uses Drug of choice for status epilepticus. Management of anxiety disorders, for short-term relief of anxiety symptoms, to allay anxiety and tension prior to surgery, cardioversion and endoscopic procedures, as an amnesic, and treatment for restless legs. Also used to alleviate acute withdrawal symptoms of alcoholism, voiding problems in older adults, and adjunctively for relief of skeletal muscle spasm associated with cerebral palsy, paraplegia, athetosis, stiff-man syndrome, tetanus. Contraindications Injectable form: Shock, coma, acute alcohol intoxication, depressed vital signs, obstetrical patients, infants <30 d of age. Tablet form: Infants <6 mo of age, acute narrow-angle glaucoma, untreated open-angle glaucoma; during or within 14 d of MAO inhibitor therapy. Safe use during pregnancy (category D) and lactation is not established. Cautious Use Epilepsy, psychoses, mental depression; myasthenia gravis; impaired hepatic or renal function; drug abuse, addiction-prone individuals. Injectable diazepam used with extreme caution in older adults, the very ill, and patients with COPD. Route & Dosage Status Epilepticus Adult: IV/IM 5-10 mg, repeat if needed at 10-15 min intervals up to 30 mg, then repeat if needed q2-4h Child: IV/IM <5 y, 0.2-0.5 mg slowly q2-5min up to 5 mg; >5 y, 1 mg slowly q2-5min up to 10 mg, repeat if needed q2-4 h Anxiety, Muscle Spasm, Convulsions, Alcohol Withdrawal Adult: PO 2-10 mg b.i.d. to q.i.d. or 15-30 mg/d sustained release IV/IM 2-10 mg, repeat if needed in 3-4 h Geriatric: PO 1-2 mg 1-2 times/d (max: 10 mg/d) Child: PO >6 mo, 1-2.5 mg b.i.d. or t.i.d. Administration Note: Dizac emulsion is administered by IV only. Oral Ensure that sustained release form is not chewed or crushed. It MUST be swallowed whole. Give other tablets crushed with fluid or mixed with food if necessary. Supervise oral ingestion to ensure drug is swallowed. Avoid abrupt discontinuation of diazepam. Taper doses to termination. Intramuscular Give deep into large muscle mass. Inject slowly. Rotate injection sites. Do NOT give emulsion form (Dizac) as IM or SC. It is for IV use only. Intravenous PREPARE: Direct: Do not dilute or mix with any other drug. ADMINISTER: Direct: Give direct IV by injecting drug slowly, taking at least 1 min for each 5 mg (1 mL) given to adults and taking at least 3 min to inject 0.25 mg/kg body weight of children. If injection cannot be made directly into vein, inject slowly through infusion tubing as close as possible to vein insertion. The emulsion form is incompatible with PVC infusion sets. Avoid small veins and take extreme care to avoid intraarterial administration or extravasation. INCOMPATIBILITIES Solution/additive: Bleomycin, benzquinamide, dobutamine, doxapram, doxorubicin, fluorouracil, glycopyrrolate, heparin, nalbuphone, sufentanil. Emulsion also incompatible with morphine. Y-site: Furosemide, heparin, potassium chloride, tirofiban, vitamin B complex with C. Emulsion also incompatible with morphine. Do not mix emulsion with any other drugs. Do not administer through polyvinyl chloride (PVC) infusion sets. Store in tight, light-resistant containers at 15°-30° C (59°-86° F), unless otherwise specified by manufacturer. Store Dizac emulsion at 2°-8° C (36°-46° F). Do not freeze. Adverse Effects (1%) Body as a Whole: Throat and chest pain. CNS: Drowsiness, fatigue, ataxia, confusion, paradoxic rage, dizziness, vertigo, amnesia, vivid dreams, headache, slurred speech, tremor; EEG changes, tardive dyskinesia. CV: Hypotension, tachycardia, edema, cardiovascular collapse. Special Senses: Blurred vision, diplopia, nystagmus. GI: Xerostomia, nausea, constipation, hepatic dysfunction. Urogenital: Incontinence, urinary retention, gynecomastia (prolonged use), menstrual irregularities, ovulation failure. Respiratory: Hiccups, coughing, laryngospasm. Other: Pain, venous thrombosis, phlebitis at injection site. Interactions Drug: Alcohol, CNS DEPRESSANTS, ANTICONVULSANTS potentiate CNS depression; cimetidine increases diazepam plasma levels, increases toxicity; may decrease antiparkinson effects of levodopa; may increase phenytoin levels; smoking decreases sedative and antianxiety effects. Herbal: Kava kava, valerian may potentiate sedation. Pharmacokinetics Absorption: Readily absorbed from GI tract; erratic IM absorption. Onset: 30-60 min PO; 15-30 min IM; 1-5 min IV. Peak: 1-2 h PO. Duration: 15 min-1 h IV; up to 3 h PO. Distribution: Crosses blood-brain barrier and placenta; distributed into breast milk. Metabolism: Metabolized in liver to active metabolites. Elimination: Excreted primarily in urine. Half-Life: 20-50 h. Nursing Implications Assessment & Drug Effects Monitor for adverse reactions. Most are dose related. Physician will rely on accurate observation and reports of patient response to the drug to determine lowest effective maintenance dose. Monitor for therapeutic effectiveness. Maximum effect may require 1-2 wk; patient tolerance to therapeutic effects may develop after 4 wk of treatment. Observe necessary preventive precautions for suicidal tendencies that may be present in anxiety states accompanied by depression. Observe patient closely and monitor vital signs when diazepam is given parenterally; hypotension, muscular weakness, tachycardia, and respiratory depression may occur. Lab tests: Periodic CBC and liver function tests during prolonged therapy. Supervise ambulation. Adverse reactions such as drowsiness and ataxia are more likely to occur in older adults and debilitated or those receiving larger doses. Dosage adjustment may be necessary. Monitor I&O ratio, including urinary and bowel elimination. Note: Smoking increases metabolism of diazepam; lowering clinical effectiveness. Heavy smokers may need a higher dose than the nonsmoker. Note: Psychic and physical dependence may occur in patients on long-term high dosage therapy, in those with histories of alcohol or drug addiction, or in those who self-medicate. Patient & Family Education Avoid alcohol and other CNS depressants during therapy unless otherwise advised by physician. Concomitant use of these agents can cause severe drowsiness, respiratory depression, and apnea. Do not drive or engage in other potentially hazardous activities or those requiring mental precision until reaction to drug is known. Tell physician if you become or intend to become pregnant during therapy; drug may need to be discontinued. Take drug as prescribed; do not change dose or dose intervals. Check with physician before taking any OTC drugs. Do not breast feed while taking this drug without consulting physician.

prednisone

Apo-Prednisone , Deltasone, Meticorten, Orasone, Panasol, Prednicen-M, Sterapred, Winpred Classifications: HORMONES AND SYNTHETIC SUBSTITUTES; ADRENAL CORTICOSTEROID; GLUCOCORTICOID Pregnancy Category: C Availability 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mg tablets; 5 mg/5 mL, 5 mg/mL solution Actions Immediate-acting synthetic analog of hydrocortisone. Effect depends on biotransformation to prednisolone, a conversion that may be impaired in patient with liver dysfunction. Less mineralocorticoid activity than hydrocortisone, but sodium retention and potassium depletion can occur. Therapeutic Effects Has antiinflammatory properties. Uses May be used as a single agent or conjunctively with antineoplastics in cancer therapy; also used in treatment of myasthenia gravis and inflammatory conditions and as an immunosuppressant. Contraindications Systemic fungal infections and known hypersensitivity; pregnancy (category C), lactation. Cautious Use Patients with infections; nonspecific ulcerative colitis; diverticulitis; active or latent peptic ulcer; renal insufficiency; hypertension; osteoporosis; myasthenia gravis. Route & Dosage Antiinflammatory Adult: PO 5-60 mg/d in single or divided doses Child: PO 0.1-0.15 mg/kg/d in single or divided doses Acute Asthma Child: PO <1 y, 1-2 mg/kg/d times 3-5 d or 10 mg q12h; 1-4 y, 20 mg q12h; 5-13 y, 30 mg q12h; >13 y, 40 mg q12h times 3-5 d Administration Oral Crush tablet and give with fluid of patient's choice if unable to swallow whole. Give at mealtimes or with a snack to reduce gastric irritation. Dose adjustment may be required if patient is subjected to severe stress (serious infection, surgery, or injury) or if a remission or disease exacerbation occurs. Do not abruptly stop drug. Reduce dose gradually by scheduled decrements (various regimens) to prevent withdrawal symptoms and permit adrenals to recover from drug-induced partial atrophy. Alternate-Day Therapy (ADT) for Patient on Long-Term Therapy With ADT, the 48-h requirement for steroids is administered as a single dose every other morning. Be aware that ADT minimizes adverse effects associated with long-term treatment while maintaining the desired therapeutic effect. See prednisone for numerous additional nursing implications. Adverse Effects (1%) CNS: Euphoria, headache, insomnia, confusion, psychosis. CV: CHF, edema. GI: Nausea, vomiting, peptic ulcer. Musculoskeletal: Muscle weakness, delayed wound healing, muscle wasting, osteoporosis, aseptic necrosis of bone, spontaneous fractures. Endocrine: Cushingoid features, growth suppression in children, carbohydrate intolerance, hyperglycemia. Special Senses: Cataracts. Hematologic: Leukocytosis. Metabolic: Hypokalemia. Interactions Drug: BARBITURATES, phenytoin, rifampin increase steroid metabolism—increased doses of prednisone may be needed; amphotericin B, DIURETICS increase potassium loss; ambenonium, neostigmine, pyridostigmine may cause severe muscle weakness in patients with myasthenia gravis; may inhibit antibody response to VACCINES, TOXOIDS. Pharmacokinetics Absorption: Readily absorbed from GI tract. Peak: 1-2 h. Duration: 1-1.5 d. Distribution: Crosses placenta; distributed into breast milk. Metabolism: Metabolized in liver. Elimination: Hypothalamus-pituitary axis suppression: 24-36 h; Excreted in urine. Half-Life: 3.5 h. Nursing Implications Assessment & Drug Effects Establish baseline and continuing data regarding BP, I&O ratio and pattern, weight, fasting blood glucose level, and sleep pattern. Start flow chart as reference for planning individualized pharmacotherapeutic patient care. Check and record BP during dose stabilization period at least 2 times daily. Report an ascending pattern. Monitor patient for evidence of HPA axis suppression during long-term therapy by determining plasma cortisol levels at weekly intervals. Lab tests: Obtain fasting blood glucose, serum electrolytes, and routine laboratory studies at regular intervals during long-term steroid therapy. Be aware that older adult patients and patients with low serum albumin are especially susceptible to adverse effects because of excess circulating free glucocorticoids. Be alert to signs of hypocalcemia (see Appendix F). Patients with hypocalcemia have increased requirements for pyridoxine (vitamin B6), vitamins C and D, and folates. Be alert to possibility of masked infection and delayed healing (antiinflammatory and immunosuppressive actions). Prednisone suppresses early classic signs of inflammation. When patient is on an extended therapy regimen, incidence of oral Candida infection is high. Inspect mouth daily for symptoms: white patches, black furry tongue, painful membranes and tongue. Monitor bone density. Compression and spontaneous fractures of long bones and vertebrae present hazards, particularly in long-term corticosteroid treatment of rheumatoid arthritis or diabetes, in immobilized patients, and older adults. Be aware of previous history of psychotic tendencies. Watch for changes in mood and behavior, emotional stability, sleep pattern, or psychomotor activity, especially with long-term therapy, that may signal onset of recurrence. Report symptoms to physician. If a patient is receiving aspirin concomitantly with a corticosteroid, salicylism may be induced when the corticosteroid dosage is decreased or discontinued. Be aware that long-term corticosteroid therapy is ordinarily not interrupted when patient undergoes major surgery, but dosage may be increased. Monitor for withdrawal syndrome (e.g., myalgia, fever, arthralgia, malaise) and hypocorticism (e.g., anorexia, vomiting, nausea, fatigue, dizziness, hypotension, hypoglycemia, myalgia, arthralgia) with abrupt discontinuation of corticosteroids after long-term therapy. Patient & Family Education Take drug as prescribed and do not alter dosing regimen or stop medication without consulting physician. Be aware that a slight weight gain with improved appetite is expected, but after dosage is stabilized, a sudden slow but steady weight increase [2 kg (5 lb) per wk] should be reported to physician. Avoid or minimize alcohol and caffeine may contribute to steroid-ulcer development in long-term therapy. Report symptoms of GI distress to physician and do not self-medicate to find relief. Do not use aspirin or other OTC drugs unless they are prescribed specifically by the physician. Report slow healing, any vague feeling of being sick, or return of pretreatment symptoms. Be fastidious about personal hygiene; give special attention to foot care, and be particularly cautious about bruising or abrading the skin. Report persistent backache or chest pain (possible symptoms of vertebral or rib fracture) that may occur with long-term therapy. Tell dentist or new physician about prednisone therapy. Carry medical information at all times. It needs to indicate medical diagnosis, medication(s), physician's name(s), address(es), and telephone number(s). Do not breast feed while taking this drug without consulting physician.

Glucagon

GlucaGen Classifications: HORMONES AND SYNTHETIC SUBSTITUTES Pregnancy Category: B Availability 1 mg powder for injection Actions Polypeptide hormone produced by alpha cells of islets of Langerhans. Stimulates uptake of amino acids and their conversion to glucose precursors. Therapeutic Effects Promotes lipolysis in liver and adipose tissue with release of free fatty acid and glycerol, which further stimulates ketogenesis and hepatic gluconeogenesis. Action in hypoglycemia relies on presence of adequate liver glycogen stores. Uses Emergency treatment of severe hypoglycemic reactions in diabetic patients who are unconscious or unable to swallow food or liquids and in psychiatric patients receiving insulin shock therapy. Also radiologic studies of GI tract to relax smooth muscle and thereby allow finer detail of mucosa; to diagnose insulinoma. Unlabeled Uses GI disturbances associated with spasm, cardiovascular emergencies, and to overcome cardiotoxic effects of beta blockers, quinidine, tricyclic antidepressants; as an aid in abdominal imaging. Contraindications Hypersensitivity to glucagon or protein compounds. Safe use during pregnancy (category B) or lactation is not established. Cautious Use Insulinemia, pheochromocytoma. Route & Dosage Hypoglycemia Adult: IM/IV/SC 0.5-1 mg, may repeat q5-20 min if no response for 1-2 more doses Child: IM/IV/SC 0.025 mg/kg (max: 1 mg/dose), may repeat q5-20 min if no response for 1-2 more doses Neonate: IM/IV/SC 0.3 mg/kg (max: 1 mg) Insulin Shock Therapy Adult: IM/IV/SC 0.5-1 mg usually 1 h after coma develops, may repeat in 25 min if no response Diagnostic Aid to Relax Stomach or Upper GI Tract Adult: IM/IV/SC 0.25-2 mg 10 min before the procedure Diagnostic Aid for Examination of Colon Adult: IM/IV/SC 2 mg 10 min before the procedure Administration Note: 1 mg 1 unit Subcutaneous/Intramuscular Dilute 1 unit (1 mg) of glucagon with 1 mL of diluent supplied by manufacturer. Use immediately after reconstitution of dry powder. Discard any unused portion. Note: Glucagon is incompatible in syringe with any other drug. Intravenous PREPARE: Direct: Prepare as noted above. Do not use a concentration >1 unit/mL. ADMINISTER: Direct: Give 1 unit or fraction thereof over 1 min. May be given through a Y-site D5W (not NS) infusing. INCOMPATIBILITIES Solution/additive: Sodium chloride. Store unreconstituted vials and diluent at 20°-25° C (68°-77° F). Adverse Effects (1%) GI: Nausea and vomiting. Body as a Whole: Hypersensitivity reactions. Skin: Stevens-Johnson syndrome (erythema multiforme). Metabolic: Hyperglycemia, hypokalemia. Pharmacokinetics Onset: 5-20 min. Peak: 30 min. Duration: 1-1.5 h. Metabolism: Metabolized in liver, plasma, and kidneys. Half-Life: 3-10 min. Nursing Implications Assessment & Drug Effects Be prepared to give IV glucose if patient fails to respond to glucagon. Notify physician immediately. Note: Patient usually awakens from (diabetic) hypoglycemic coma 5-20 min after glucagon injection. Give PO carbohydrate as soon as possible after patient regains consciousness. Note: After recovery from hypoglycemic reaction, symptoms such as headache, nausea, and weakness may persist. Patient & Family Education Note: Physician may request that a responsible family member be taught how to administer glucagon SC or IM for patients with frequent or severe hypoglycemic reactions. Notify physician promptly whenever a hypoglycemic reaction occurs so the reason for the reaction can be determined. Review package insert and directions (see ADMINISTRATION). Do not breast feed while taking this drug without consulting physician

Glieizidi

Glucotrol, Glucotrol XL Classifications: HORMONES AND SYNTHETIC SUBSTITUTES; ANTIDIABETIC AGENT; SULFONYLUREA Prototype: Glyburide Pregnancy Category: C Availability 5 mg, 10 mg tablets; 5 mg, 10 mg sustained release tablets Actions Second generation sulfonylurea hypoglycemic agent. Potency is enhanced by as much as 200-fold over first generation agents. Therapeutic Effects Directly stimulates functioning pancreatic beta cells to secrete insulin, leading to an acute drop in blood glucose. Indirect action leads to altered numbers and sensitivity of peripheral insulin receptors, resulting in increased insulin binding. It also causes inhibition of hepatic glucose production and reduction in serum glucagon levels. Uses Adjunct to diet for control of hyperglycemia in patient with type 2 diabetes mellitus after dietary control alone has failed; also used to treat transient loss of control in patient usually controlled well on diet. Contraindications Diabetic ketoacidosis. Safe use during pregnancy (category C), lactation, or in children is not established. Cautious Use Impaired renal and hepatic function; older adults; debilitated, malnourished patients; patients with adrenal or pituitary insufficiency. Route & Dosage Control of Hyperglycemia Adult: PO 2.5-5 mg/d 30 min before breakfast, may increase by 2.5-5 mg q1-2wk; >15 mg/d in divided doses 30 min before morning and evening meal (max: 40 mg/d); 5-10 mg sustained release tablets once/d Administration Oral Give once-daily dosing 30 min before the first meal of the day. Ensure that sustained release form of drug is not chewed or crushed. It must be swallowed whole. Store in tightly closed, light-resistant container at 15°-30° C (59°-86° F). Adverse Effects (1%) GI: Nausea, diarrhea, constipation, gastralgia, cholestatic jaundice (rare). Metabolic: Hepatic porphyria, hypoglycemia. Skin: Erythema, morbilliform or maculopapular rash, pruritus, urticaria, eczema (transient). Body as a Whole: Hypersensitivity (fatigue, drowsiness, hunger, GI distress with heartburn, abdominal pain, anorexia). CNS: Transient drowsiness, headache, anxiety, ataxia, confusion; seizures, coma. CV: Tachycardia. Special Senses: Visual disturbances. Interactions Drug: Alcohol produces disulfiram-like reaction in some patients; ORAL ANTICOAGULANTS, chloramphenicol, clofibrate, phenylbutazone, MAO INHIBITORS, SALICYLATES, probenecid, SULFONAMIDES may potentiate hypoglycemic actions; THIAZIDES may antagonize hypoglycemic effects; cimetidine may increase glipizide levels, causing hypoglycemia. Herbal: Ginseng, garlic may increase hypoglycemic effects. Pharmacokinetics Absorption: Readily absorbed from GI tract. Onset: 15-30 min. Peak: 1-2 h. Duration: up to 24 h. Metabolism: Metabolized extensively in liver. Elimination: Excreted mainly in urine with some excretion via bile in feces. Half-Life: 3-5 h. Nursing Implications Assessment & Drug Effects Observe response to the initial dose and establish maintenance regimen cautiously in older adult or debilitated patients; early signs of hypoglycemia are easily overlooked. Lab tests: monitor periodically during long-term therapy: Liver function tests, serum electrolytes, and serum osmolarity. Note: Severe drug-induced skin rashes and pruritus may necessitate discontinuation of drug use. Symptoms usually subside rapidly when drug is withdrawn. Check urine for sugar and ketone bodies at least 3 times daily during insulin withdrawal and transfer to glipizide. Contact physician if tests are abnormal. Note: Patients transferred from a sulfonylurea with a long half-life (e.g., chlorpropamide, half-life: 30-40 h) must be observed for hypoglycemic responses (see Appendix F) for 1-2 wk because of potential overlapping of drug effect. Note: The first signs of hypoglycemia may be hard to detect in patients receiving concurrent beta blockers or older adults. Patient & Family Education Overdose treatment: Treat mild hypoglycemia (reaction without loss of consciousness or neurologic symptoms) with PO glucose and adjustment of dosage and meal pattern; monitor closely for at least 5-7 d to assure reestablishment of safe control. Severe hypoglycemia requires emergency hospitalization to permit treatment to maintain a blood glucose level above 100 mg/dL. Note: Glipizide therapy accompanies (does NOT substitute for) continued control of diet and (if patient is obese) a weight-loss program. Test fasting and postprandial blood glucose frequently. Exercise is an important part of the total control program. When a drug that affects the hypoglycemic action of sulfonylureas (see DRUG INTERACTIONS) is withdrawn or added to the glipizide regimen, be alert to the added danger of loss of control. Urine and blood glucose tests and test for ketone bodies should be carefully monitored. Do not breast feed while taking this drug without consulting physician

glipizide

Insulin Isophane NPH

Humulin N, Insulatard NPH, Mixtard, Novolin 70/30, Novolin N Classifications: HORMONE AND SYNTHETIC SUBSTITUTE; ANTIDIABETIC AGENT; INTERMEDIATE ACTING INSULIN Prototype: Insulin Pregnancy Category: B Availability 100 units/mL Actions Intermediate-acting, cloudy suspension of zinc insulin crystals modified by protamine in a neutral buffer. NPH Iletin II (pork), and Insulatard NPH are "purified" or "single component" insulins that have been purified and are less likely to cause allergic reactions than nonpurified preparations. Therapeutic Effects Lowers blood glucose levels by increasing peripheral glucose uptake, especially by skeletal muscle and fat tissue, and by inhibiting the liver from changing glycogen to glucose. Therapeutic effect controls postprandial hyperglycemia, usually without supplemental doses of insulin injection. Uses Used to control hyperglycemia in the diabetic patient. Mixtard and Novolin 70/30 are fixed combinations of purified regular insulin 30% and NPH 70%. Contraindications During episodes of hypoglycemia or in patients sensitive to any ingredient in the formulation. Cautious Use In insulin resistant patients, hyperthyroidism or hypothyroidism; lactation, older adults, pregnancy (category B), renal or hepatic impairment. Safety and efficacy in children <3 y are not established. Route & Dosage Diabetes Mellitus Adult: SC Individualized doses (see INSULIN, REGULAR) Administration Subcutaneous Give isophane insulin 30 min before first meal of the day. If necessary, a second smaller dose may be prescribed 30 min before supper or at bedtime. Ensure complete dispersion by mixing thoroughly by gently rotating vial between palms and inverting it end to end several times. Do not shake. Do NOT mix insulins unless prescribed by physician. In general, when insulin injection (regular insulin) is to be combined, it is drawn first. Note: Isophane insulin may be mixed with insulin injection without altering either solution. Do NOT mix with Lente forms. Store unopened vial at 2°-8° C (36°-46° F). Avoid freezing and exposure to extremes in temperature or to direct sunlight. Adverse Effects (1%) (see INSULIN, REGULAR). Interactions (see INSULIN, REGULAR). Pharmacokinetics Onset: 1-2 h. Peak: 4-12 h NPH. Duration: 18-24 h NPH. Metabolism: Metabolized in liver and kidney. Elimination: <2% excreted unchanged in urine. Half-Life: up to 13 h. Nursing Implications (see INSULIN, REGULAR) Assessment & Drug Effects Suspect hypoglycemia if fatigue, weakness, sweating, tremor, or nervousness occur. Patient & Family Education If insulin was given before breakfast, a hypoglycemic episode is most likely to occur between mid-afternoon and dinnertime, when insulin effect is peaking. Advise to eat a snack in mid-afternoon and to carry sugar or candy to treat a reaction. A snack at bedtime will prevent insulin reaction during the night. Learn the S&S of hypoglycemia and hyperglycemia (see Appendix F). Do not breast feed while taking this drug without consulting physician

Exenatide

Humulin R, Novolin R, Regular Insulin, Velosulin, Velosulin BR, Velosulin Human Classifications: HORMONE AND SYNTHETIC SUBSTITUTE; ANTIDIABETIC AGENT; INSULIN Pregnancy Category: B Availability 100 units/mL Actions Short-acting, clear, colorless solution of exogenous unmodified insulin extracted from beta cells in pork pancreas or synthesized by recombinant DNA technology (human). Enhances transmembrane passage of glucose across cell membranes of most body cells and by unknown mechanism may itself enter the cell to activate selected intermediary metabolic processes. Promotes conversion of glucose to glycogen. Therapeutic Effects It lowers blood glucose levels by increasing peripheral glucose uptake, especially by skeletal muscle and fat tissue, and by inhibiting the liver from changing glycogen to glucose. Uses Emergency treatment of diabetic ketoacidosis or coma, to initiate therapy in patient with insulin-dependent diabetes mellitus, and in combination with intermediate-acting or long-acting insulin to provide better control of blood glucose concentrations in the diabetic patient. Used IV to stimulate growth hormone secretion (glucose counter regulatory hormone) to evaluate pituitary growth hormone reserve in patient with known or suspected growth hormone deficiency. Other uses include promotion of intracellular shift of potassium in treatment of hyperkalemia (IV) and induction of hypoglycemic shock as therapy in psychiatry. Contraindications Hypersensitivity to insulin animal protein. Cautious Use Pregnancy (category B), lactation, renal impairment, hepatic impairment, and older adults. Safety and efficacy in children <2 y are not established. Route & Dosage Diabetes Mellitus Adult: SC 5-10 U 15-30 min a.c. and h.s. (dose adjustments based on blood glucose determinations) Child: SC 2-4 U 15-30 min a.c. and h.s. (dose adjustments based on blood glucose determinations) Ketoacidosis Adult: IV 2.4-7.2 U loading dose, followed by 2.4-7.2 U/h continuous infusion Child: IV 0.1 U/kg loading dose, followed by 0.1 U/h continuous infusion Administration Note: Insulins should not be mixed unless prescribed by physician. In general, regular insulin is drawn up into syringe first. Any change in the strength (e.g., U-40, U-100), brand (manufacturer), purity, type (regular, etc.), species (pork, human), or sequence of mixing two kids of insulin is made by the physician only, since a simultaneous change in dosage may be necessary. Subcutaneous Use an insulin syringe. Give regular insulin 30 min before a meal. Avoid injection of cold insulin; it can lead to lipodystrophy, reduced rate of absorption, and local reactions. Common injection sites: Upper arms, thighs, abdomen [avoid area over urinary bladder and 2 in. (5 cm) around navel], buttocks, and upper back (if fat is loose enough to pick up). Rotate sites. Intravenous PREPARE: Direct: Give undiluted. Continuous: Typically diluted in NS or 0.45% NaCl. 100 U added to 1000 mL yields 0.1 U/mL. ADMINISTER: Direct: Give 50 U or a fraction thereof over 1 min. Continuous: Rate must be ordered by physician. INCOMPATIBILITIES Solution/additive: Aminophylline, amobarbital, chlorothiazide, cytarabine, dobutamine, pentobarbital, phenobarbital, phenytoin, secobarbital, sodium bicarbonate, thiopental. Y-site: Dobutamine. Regular insulin may be adsorbed into the container or tubing when added to an IV infusion solution. Amount lost is variable and depends on concentration of insulin, infusion system, contact duration, and flow rate. Monitor patient response closely. Insulin is stable at room temperature up to 1 mo. Avoid exposure to direct sunlight or to temperature extremes [safe range is wide: 5°-38° C (40°-100° F)]. Refrigerate but do not freeze stock supply. Insulin tolerates temperatures above 38° C with less harm than freezing. Adverse Effects (1%) Body as a Whole: Most adverse effects are related to hypoglycemia; anaphylaxis (rare), hyperinsulinemia [Profuse sweating, hunger, headache, nausea, tremulousness, tremors, palpitation, tachycardia, weakness, fatigue, nystagmus, circumoral pallor; numb mouth, tongue, and other paresthesias; visual disturbances (diplopia, blurred vision, mydriasis), staring expression, confusion, personality changes, ataxia, incoherent speech, apprehension, irritability, inability to concentrate, personality changes, uncontrolled yawning, loss of consciousness, delirium, hypothermia, convulsions, Babinski reflex, coma. (Urine glucose tests will be negatives). CNS: With overdose, psychic disturbances (i.e., aphasia, personality changes, maniacal behavior). Metabolic: Posthypoglycemia or rebound hyperglycemia (Somogyi effect), lipoatrophy and lipohypertrophy of injection sites; insulin resistance. Skin: Localized allergic reactions at injection site; generalized urticaria or bullae, lymphadenopathy. Diagnostic Test Interference Large doses of insulin may increase urinary excretion of VMA. Insulin can cause alterations in thyroid function tests and liver function test and may decrease serum potassium and serum calcium. Interactions Drug: Alcohol, ANABOLIC STEROIDS, MAO INHIBITORS, guanethidine, SALICYLATES may potentiate hypoglycemic effects; dextrothyroxine, CORTICOSTEROIDS, epinephrine may antagonize hypoglycemic effects; furosemide, THIAZIDE DIURETICS increase serum glucose levels; propranolol and other BETA BLOCKERS may mask symptoms of hypoglycemic reaction. Herbal: Garlic, ginseng may potentiate hypoglycemic effects. Pharmacokinetics Absorption: Rapidly absorbed from IM and SC injections. Onset: 0.5-1 h. Peak: 2-3 h. Duration: 5-7 h. Distribution: Throughout extracellular fluids. Metabolism: Metabolized primarily in liver with some metabolism in kidneys. Elimination: <2% excreted in urine. Half-Life: Biological, up to 13 h. Nursing Implications Assessment & Drug Effects Note: Frequency of blood glucose monitoring is determined by the type of insulin regimen and health status of the patient. Lab tests: Periodic postprandial blood glucose, and HbA1C. Test urine for ketones in new, unstable, and type 1 diabetes; if patient has lost weight, exercises vigorously, or has an illness; whenever blood glucose is substantially elevated. Notify physician promptly for presence of acetone with sugar in the urine; may indicate onset of ketoacidosis. Acetone without sugar in the urine usually signifies insufficient carbohydrate intake. Monitor for hypoglycemia (see Appendix F) at time of peak action of insulin. Onset of hypoglycemia (blood sugar: 50-40 mg/dL) may be rapid and sudden. Check BP, I&O ratio, and blood glucose and ketones every hour during treatment for ketoacidosis with IV insulin. Give patients with severe hypoglycemia glucagon, epinephrine, or IV glucose 10-50%. As soon as patient is fully conscious, give oral carbohydrate (e.g., dilute corn syrup or orange juice with sugar, Gatorade, or Pedialyte) to prevent secondary hypoglycemia. Patient & Family Education Learn correct injection technique. Inject insulin into the abdomen rather than a near muscle that will be heavily taxed, if engaged in active sports. Notify physician of local reactions at injection site; may develop 1-3 wk after therapy starts and last several hours to days, usually disappear with continued use. Do not change prescription lenses during early period of dosage regulation; vision stabilizes, usually 3-6 wk. Note: Hypoglycemia can result from excess insulin, insufficient food intake, vomiting, diarrhea, unaccustomed exercise, infection, illness, nervous or emotional tension, or overindulgence in alcohol. Respond promptly to beginning symptoms of hypoglycemia. Severe hypoglycemia is an emergency situation. Take 4 oz (120 mL) of any fruit juice or regular carbonated beverage [1.5-3 oz (45-90 mL) for child] followed by a meal of longer-acting carbohydrate or protein food. Failure to show signs of recovery within 30 min indicates need for emergency treatment. Carry some form of fast-acting carbohydrate (e.g., lump sugar, Life-Savers or other candy) at all times to treat hypoglycemia. Check blood glucose regularly during menstrual period; loss of diabetes control (hyperglycemia or hypoglycemia) is common; adjust insulin dosage accordingly, as prescribed by physician. Notify physician of S&S of diabetic ketoacidosis. Continue taking insulin during an illness, go to bed, and drink noncaloric liquids liberally (every hour if possible). Consult physician for insulin regulation if unable to eat prescribed diet. Avoid OTC medications unless approved by physician. Do not breast feed while taking this drug without consulting physician

Regular Insulin

Levothyroxine

Levothroid, Levoxyl, Levo-T, Synthroid Classifications: HORMONES AND SYNTHETIC SUBSTITUTES; THYROID AGENT Pregnancy Category: A Availability 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg 175 mcg, 200 mcg, 300 mcg tablets; 200 mcg, 500 mcg vials Actions Synthetically prepared monosodium salt and levo-isomer of thyroxine, with similar actions and uses (thyroxine, principal component of thyroid gland secretions, determines normal thyroid function). Therapeutic Effects Principal effects includes diuresis, loss of weight and puffiness, increased sense of well-being and activity tolerance, and rise of T3 and T4 serum levels toward normal. Uses Specific replacement therapy for diminished or absent thyroid function resulting from primary or secondary atrophy of gland, surgery, excessive radiation or antithyroid drugs, congenital defect. Administered orally for hypothyroid state; administered IV for myxedematous coma or other thyroid dysfunctions demanding rapid replacement, as well as in failure to respond to oral therapy. Contraindications Hypersensitivity to levothyroxine; thyrotoxicosis, severe cardiovascular conditions, adrenal insufficiency. Cautious Use Angina pectoris, hypertension, impaired kidney function, pregnancy (category A), lactation. Route & Dosage Thyroid Replacement Adult: PO 25-50 mcg/d, gradually increased by 50-100 mcg q1-4wk to usual dose of 100-400 mcg/d IV ½ of usual PO dose Child: PO 0-6 mo, 8-10 mcg/kg/d or 25-50 mcg/d; 6-12 mo, 6-8 mcg/kg/d or 50-75 mcg/d; 1-5 y, 5-6 mcg/kg/d or 75-100 mcg/d; 6-12 y, 4-5 mcg/kd/d or 100-150 mcg/d; >12 y, 2-3 mcg/kg/d or >150 mcg/d IV ½ of usual PO dose Myxedema Coma Adult: IV 250-500 mcg IV stat, then 100-300 mcg after 24 h if needed, then 50-200 mcg/d until patient is stable and can take drug PO Administration Oral Give as a single dose, preferably 1 h before or 2 h after breakfast, to prevent insomnia. Give consistently with respect to meals. Maintenance dosage for older adults may be 25% lower than for heavier and younger adults. Intravenous PREPARE: Direct: Reconstitute by adding 5 mL NS for injection immediately before administration. Shake vial until solution is clear. Do NOT mix with IV solutions. Discard unused portion. ADMINISTER: Direct: Give at a rate of 0.1 mg or a fraction thereof over 1 min into a Y-site closest to needle insertion. Give IMMEDIATELY after reconstitution. Store in tight, light-resistant container. Adverse Effects (1%) CNS: Irritability, nervousness, insomnia, headache (pseudotumor cerebri in children), tremors, craniosynostosis (excessive doses in children). CV: Palpitations, tachycardia, arrhythmias, angina pectoris, hypertension. GI: Nausea, diarrhea, change in appetite. Urogenital: Menstrual irregularities. Body as a Whole: Weight loss, heat intolerance, sweating, fever, leg cramps, temporary hair loss (children). Interactions Drug: Cholestyramine, colestipol decrease absorption of levothyroxine; epinephrine, norepinephrine increase risk of cardiac insufficiency; ORAL ANTICOAGULANTS may potentiate hypoprothrombinemia. Pharmacokinetics Absorption: Variable and incompletely absorbed from GI tract (50-80%). Peak: 3-4 wk. Duration: 1-3 wk. Distribution: Gradually released into tissue cells. Half-Life: 6-7 d. Nursing Implications Assessment & Drug Effects Monitor pulse before each dose during dose adjustment. If rate is >100, consult physician. Monitor for adverse effects during early adjustment. If metabolism increases too rapidly, especially in older adults and heart disease patients, symptoms of angina or cardiac failure may appear. Note: Levothyroxine may aggravate severity of previously obscured symptoms of diabetes mellitus, Addison's disease, or diabetes insipidus. Therapy for these disorders may require adjustment. Lab tests: Baseline and periodic tests of thyroid function. Closely monitor PT/INR and assess for evidence of bleeding if patient is receiving concurrent anticoagulant therapy. A decrease in anticoagulant dosage may be needed 1-4 wk after concurrent levothyroxine is started. Monitor bone age, growth, and psychomotor function in children. Some children have partial hair loss after a few months; it returns even with continued therapy. Synthroid 100 and 300 mcg tablets contain tartrazine, which may cause an allergic-type reaction in certain patients; particularly those who are hypersensitive to aspirin. Patient & Family Education Thyroid replacement therapy is usually lifelong. Learn how to self-monitor pulse rate. Notify physician if rate begins to increase above 100 or if rhythm changes are noted. Notify physician immediately of signs of toxicity (e.g., chest pain, palpitations, nervousness). Avoid OTC medications unless approved by physician. Do not breast feed while taking this drug without consulting physician

Oprelvekin

Neumega Classifications: BLOOD FORMERS, COAGULATORS, AND ANTICOAGULANTS; HEMATOPOIETIC GROWTH FACTOR Prototype: Epoetin Alfa Pregnancy Category: C Availability 5 mg injection Actions Hematopoietic growth factor (interleukin-11) that is produced by recombinant DNA. Therapeutic Effects Indicated by return of postnadir platelet count toward normal (50,000). Increases platelet count in a dose-dependent manner. Uses Prevention of severe thrombocytopenia following myelosuppressive chemotherapy (not effective after myeloablative chemotherapy). Contraindications Hypersensitivity to oprelvekin; myeloablative chemotherapy; myeloid malignancies; pregnancy (category C). Cautious Use Patients with left ventricular dysfunction, cardiac disease, CHF, history of atrial arrhythmias, or other arrhythmias; electrolyte imbalance, hypokalemia; respiratory disease; papilledema; thromboembolic disorders; older adults; cerebrovascular disease, stroke, TIAs; pleural effusion, pericardial effusion, ascites; increased intracranial pressure, brain tumor, visual disturbances; hepatic or renal dysfunction; lactation. Route & Dosage Thrombocytopenia Adult: SC 50 mcg/kg once daily starting 6-24 h after completing chemotherapy and continuing until platelet count is 50,000 cells/mcL or up to 21 d Child: SC 8 mo-17 y, 75-100 mcg/kg once daily starting 6-24 h after completing chemotherapy and continuing until platelet count is 50,000 cells/mcL or up to 21 d Administration Note: Do not use if solution is discolored or if it contains particulate matter. Subcutaneous Reconstitute solution by gently injecting 1 mL of sterile water for injection (without preservative) toward the sides of the vial. Keep needle in vial and gently swirl to dissolve but do not shake solution. Without removing needle, withdraw specified amount of oprelvekin for injection. Give as single dose into the abdomen, thigh, hip, or upper arm. Discard any unused portion of the vial. It contains no preservatives. Use reconstituted solution within 3 h; store at 2°-8° C (36°-46° F) until used. Store unopened vials at 2°-8° C (36°-46° F). Do not freeze. Adverse Effects (1%) Body as a Whole: Edema, neutropenic fever, fever, asthenia, pain, chills, myalgia, bone pain, dehydration. CNS: Headache, dizziness, insomnia, nervousness. CV: Tachycardia, vasodilation, palpitations, syncope, atrial fibrillation/flutter, peripheral edema, capillary leak syndrome. GI: Nausea, vomiting, mucositis, diarrhea, oral moniliasis, anorexia, constipation, dyspepsia. Hematologic: Ecchymosis. Respiratory: Dyspnea, rhinitis, cough, pharyngitis, pleural effusion, pulmonary edema, exacerbation of preexisting pleural effusion. Skin: Alopecia, rash, skin discoloration, exfoliative dermatitis. Special Senses: Conjunctival injection, amblyopia. Interactions Drug: No clinically significant interactions established. Pharmacokinetics Absorption: 80% absorbed from SC injection site. Onset: Days 5-9. Duration: 7 d after last dose. Distribution: Distributes to highly perfused organs. Elimination: Excreted in urine. Half-Life: 6.9 h. Nursing Implications Assessment & Drug Effects Lab tests: Monitor platelet counts until adequate recovery; periodically monitor CBC with differential and serum electrolytes. Monitor carefully for and immediately report S&S of fluid overload, hypokalemia, and cardiac arrhythmias. Monitor persons with preexisting fluid retention carefully (e.g., CHF, pleural effusion, ascites) for worsening of symptoms. Patient & Family Education Review patient information leaflet with special attention to administration directions. Report any of the following to the physician: Shortness of breath, edema of arms and/or legs, chest pain, unusual fatigue or weakness, irregular heartbeat, blurred vision. Do not breast feed while taking this drug

Fluoxetine

Prozac, Prozac Weekly, Sarafem Classifications: CENTRAL NERVOUS SYSTEM AGENT; PSYCHOTHERAPEUTIC AGENT; SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRI) Pregnancy Category: C Availability 10 mg tablets; 10 mg, 20 mg capsules; 20 mg/5 mL solution; 90 mg sustained-release capsules (Prozac Weekly) Actions Oral antidepressant chemically unrelated to tricyclic, tetracyclic, MAOI, or other available antidepressants. Antidepressant effect is presumed to be linked to its inhibition of CNS neuronal uptake of serotonin, a neurotransmitter. Known as a selective serotonin reuptake inhibitor (SSRI). Therapeutic Effects Effectiveness may take from several days to 5 wk to develop fully. Drug has antidepressant, antiobsessive-compulsive, and antibulimic actions. Uses Depression, geriatric depression, obsessive-compulsive disorder (OCD), bulimia nervosa, premenstrual dysphoric disorder. Unlabeled Uses Obesity. Contraindications Hypersensitivity to fluoxetine or other SSRI drugs; concurrent administration with MAOIs, or thioridazine; pregnancy (category C), children <7 y for OCD, children <8 y for depression. Cautious Use Hepatic and renal impairment, renal failure, abrupt discontinuation, anorexia nervosa, mania, bleeding, lactation; hyponatremia, cardiac disease, dehydration, diabetes mellitus, patients with history of suicidal ideations; seizure disorders, ECT, hepatic disease. Older adults may require dose adjustments. Route & Dosage Depression, Obsessive-Compulsive Disorder Adult: PO 20 mg/d in a.m., may increase by 20 mg/d at weekly intervals (max: 80 mg/d); 20 mg/d in a.m.; when stable may switch to 90 mg sustained-release capsule qwk (max: 90 mg/wk) Child: PO > 7 y 10-20 mg/d in a.m. (max: 60 mg/d for OCD) Geriatric: PO Start with 10 mg/d Premenstrual Dysphoric Disorder Adult: PO 10-20 mg q.d. (max: 60 mg/d) Bulimia Nervosa Adult: PO 60 mg q.d. Administration Oral Give as a single dose in morning. Give in two divided doses; one in a.m. and one at noon to prevent insomnia, when more than 20 mg/d prescribed. Provide suicidal or potentially suicidal patient with small quantities of prescription medication. Monitor for worsening of depression or expression of suicidal ideations. Store at 15°-25° C (59°-77° F). Adverse Effects (1%) CNS: Headache, nervousness, anxiety, insomnia, drowsiness, fatigue, tremor, dizziness. CV: Palpitations, hot flushes, chest pain. GI: Nausea, diarrhea, anorexia, dyspepsia, increased appetite, dry mouth. Skin: Rash, pruritus, sweating, hypersensitivity reactions. Special Senses: Blurred vision. Body as a Whole: Myalgias, arthralgias, flu-like syndrome, hyponatremia. Urogenital: Sexual dysfunction, menstrual irregularities. Interactions Drug: Concurrent use of tryptophan may cause agitation, restlessness, and GI distress; MAO INHIBITORS, selegiline may increase risk of severe hypertensive reaction and death; increases half-life of diazepam; may increase toxicity of TRICYCLIC ANTIDEPRESSANTS; AMPHETAMINES, cilostazol, nefazodone, pentazocine, propafenone, sibutramine, tramadol, venlafaxine may increase risk of serotonin syndrome; may inhibit metabolism of carbamazepine, phenytoin, ritonavir; increased ergotamine toxicity with dihydroergotamine, ergotamine. Herbal: St. John's wort may cause serotonin syndrome. Pharmacokinetics Absorption: 60-80% absorbed from GI tract. Onset: 1-3 wk. Peak: 4-8 h. Distribution: Widely distributed, including CNS. Metabolism: Metabolized in liver to active metabolite, norfluoxetine. Elimination: >80% excreted in urine; 12% in feces. Half-Life: Fluoxetine 2-3 d, norfluoxetine 7-9 d. Nursing Implications Assessment & Drug Effects Use with caution in the older adult patient or patient with impaired renal or hepatic function (may need lower dose). Use with caution in anorexic patient, since weight loss is a possible side effect. Monitor for S&S of anaphylactoid reaction (see Appendix F). Lab tests: Periodic serum electrolytes; monitor closely plasma glucose in diabetes. Monitor serum sodium level for development of hyponatremia, especially in patients who are taking diuretics or are otherwise hypovolemic. Monitor diabetics for loss of glycemic control; hypoglycemia has occurred during initiation of therapy, and hyperglycemia during drug withdrawal. Monitor for S&S of improved affect. Requires approximately 2-3 wk for therapeutic effects to be felt. Weigh weekly to monitor weight loss, particularly in the older adult or nutritionally compromised patient. Report significant weight loss to physician. Observe for and promptly report rash or urticaria and S&S of fever, leukocytosis, arthralgias, carpal tunnel syndrome, edema, respiratory distress, and proteinuria. Drug may have to be discontinued or adjunctive therapy instituted with steroids or antihistamines. Observe for dizziness and drowsiness and employ safety measures (up with assistance, side rails, etc.) as indicated. Monitor for and report increased anxiety, nervousness, or insomnia; may need modification of drug dose. Monitor for seizures in patients with a history of seizures. Use appropriate safety precautions. Supervise patients closely who are high suicide risks; especially during initial therapy. Monitor patients with hepatic or renal impairment carefully for S&S of toxicity (e.g., agitation, restlessness, nausea, vomiting, seizures). Patient & Family Education Notify physician of intent to become pregnant. Notify physician of any rash; possible sign of a serious group of adverse effects. Do not drive or engage in potentially hazardous activities until response to drug is known; especially if dizziness noted. Monitor blood glucose for loss of glycemic control if diabetic. Note: Drug may increase seizure activity in those with history of seizure. Do not breast feed while taking this drug without consulting physician.

Risperidol

Risperdal, Risperdal M-TAB, Risperdal Consta Classifications: CENTRAL NERVOUS SYSTEM (CNS) AGENT; ANTIPSYCHOTIC; ATYPICAL Prototype: Clozapine Pregnancy Category: C Availability 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg tablets; 0.5 mg, 1 mg, 2 mg quick-dissolving tablets; 1 mg/mL solution; 25 mg, 37.5 mg, 50 mg injection Actions Mechanism is not well understood. Interferes with binding of dopamine to D2-interlimbic region of the brain, serotonin (5-HT2) receptors, and alpha-adrenergic receptors in the occipital cortex. It has low to moderate affinity for the other serotonin (5-HT) receptors and no affinity to nondopaminergic sites (e.g., cholinergic, muscarinic, or beta-adrenergic receptors). Therapeutic Effects Effective in controlling symptoms of schizophrenia as well as other psychotic symptoms. Uses Reduction or elimination of psychotic symptoms in schizophrenia and related psychoses; treatment of bipolar disorder. Seems to improve negative symptoms such as apathy, blunted affect, and emotional withdrawal. Unlabeled Uses Management of patients with dementia-related psychotic symptoms. Adjunctive treatment of behavioral disturbances in patients with mental retardation. Contraindications Hypersensitivity to risperidone; elderly with dementia-related psychosis; QT prolongation, Reye's syndrome, brain tumor, severe CNS depression, head trauma; suicidal ideation, tardive dyskinesia; sunlight (UV) exposure, tanning beds; pregnancy (category C), lactation, children <15 y. Cautious Use Older adults; arrhythmias, hypotension, breast cancer, blood dyscrasia, cardiac disorders, cerebrovascular disease, hypotension, dehydration, diabetes mellitus, diabetic ketoacidosis, hyperglycemia, hypokalemia, hypomagnesemia, hyponatremia, MI, obesity, orthostatic hypotension, mild or moderate CNS depression, coma; GI obstruction, dysphagia; electrolyte imbalance, ethanol intoxication, heart failure, renal or hepatic dysfunction; seizure disorder, seizures, stroke, Parkinson's disease. Route & Dosage Psychosis Adult: PO 1-6 mg b.i.d., start with 1 mg b.i.d., increase by 1 mg b.i.d. daily to an initial target dose of 3 mg b.i.d. (max: 8 mg/d) IM 25 mg once q2wk (max: 50 mg) Geriatric: PO Start with 0.5 mg b.i.d. and increase by 0.5 mg b.i.d. daily to an initial target of 1.5 mg b.i.d. (max: 4 mg/d) IM 25 mg once q2wk (max: 25 mg) Bipolar Disorder Adult: PO 2-3 mg once daily for up to 3 wk Geriatric: PO Start with 0.5 mg b.i.d. and increase by 0.5 mg b.i.d. daily to an initial target of 1.5 mg b.i.d. (max: 4 mg/d). May convert to once daily dosing after stabilized in b.i.d. 2-3 d Dementia-Related Psychotic Symptoms Geriatric: PO Start with 0.5 mg b.i.d., increase by 0.5 mg b.i.d. daily to an initial target of 1 mg b.i.d. (max: 2 mg/d) Renal Impairment Clcr <30 mL/min: Start with 0.5 mg b.i.d., increase by 0.5 mg b.i.d. daily to an initial target of 1.5 mg b.i.d., may increase by 0.5 mg b.i.d. at weekly intervals (max: 6 mg/d) Administration Oral Note that quick-dissolving tablets dissolve rapidly when placed on tongue. Do not exceed increases/decreases of 1 mg b.i.d. in normal populations or 0.5 mg b.i.d. in older adults or the debilitated during dosage adjustments. Make further increases at 1-wk or longer intervals after the target dose of 3 mg b.i.d. in normal populations and 1.5 mg b.i.d. in older adults or the debilitated are reached. Store at 15°-30° C (59°-86° F). Intramuscular Reconstitute the 25, 37.5, or 50 mg vial using the supplied 2 mL prefilled syringe. Shake vigorously for at least 10 sec to produce a uniform, thick, milky suspension. If 2 min or more pass before injection, shake vial again. Give deep IM into the upper-outer quadrant of the gluteal muscle with the supplied needle; do not substitute. Follow the manufacturer's instructions for use of the SmartSite Needle-Free Vial Access Device and Needle-Pro device. Store unopened vials at 2°-8° C (36°-46° F). Protect from light. Adverse Effects (1%) Body as a Whole: Orthostatic hypotension with initial doses, sweating, weakness, fatigue. CNS: Sedation, drowsiness, headache, transient blurred vision, insomnia, disinhibition, agitation, anxiety, increased dream activity, dizziness, catatonia, extrapyramidal symptoms (akathisia, dystonia, pseudoparkinsonism), especially with doses >10 mg/d, neuroleptic malignant syndrome (rare), increased risk of stroke in elderly. CV: Prolonged QTc interval, tachycardia. GI: Dry mouth, dyspepsia, nausea, vomiting, diarrhea, constipation, abdominal pain, elevated liver function tests (AST, ALT). Endocrine: Galactorrhea. Metabolic: Hyperglycemia, diabetes mellitus. Respiratory: Rhinitis, cough, dyspnea. Skin: Photosensitivity. Urogenital: Urinary retention, menorrhagia, decreased sexual desire, erectile dysfunction, sexual dysfunction male and female. Diagnostic Test Interference Liver function tests (AST, ALT) are elevated. Interactions Drug: Risperidone may enhance the effects of certain ANTIHYPERTENSIVE AGENTS. May antagonize the antiparkinson effects of bromocriptine, cabergoline, levodopa, pergolide, pramipexole, ropinirole. Carbamazepine may decrease risperidone levels. Clozapine may increase risperidone levels. Pharmacokinetics Absorption: Rapidly absorbed; not affected by food. Onset: Therapeutic effect 1-2 wk. Peak: 1-2 h. Distribution: 0.7 L/kg; in animal studies, risperidone has been found in breast milk. Metabolism: Metabolized primarily in liver by cytochrome P450 with an active metabolite, 9-hydroxyrisperidone. Elimination: 70% excreted in urine; 14% in feces. Half-Life: 20 h for slow metabolizers, 30 h for fast metabolizers. Nursing Implications Assessment & Drug Effects Monitor diabetics for loss of glycemic control. Reassess patients periodically and maintain on the lowest effective drug dose. Monitor closely neurologic status of older adults. Monitor cardiovascular status closely; assess for orthostatic hypotension, especially during initial dosage titration. Monitor closely those at risk for seizures. Assess degree of cognitive and motor impairment, and assess for environmental hazards. Lab tests: Monitor periodically blood glucose, serum electrolytes, liver function, and complete blood counts. Patient & Family Education Carefully monitor blood glucose levels if diabetic. Do not engage in potentially hazardous activities until the response to drug is known. Be aware of the risk of orthostatic hypotension. Learn adverse effects and report to physician those that are bothersome. Wear sunscreen and protective clothing to avoid photosensitivity. Notify physician if you intend to or become pregnant. Do not breast feed while taking this drug.

Sucralfate

Carafate, Sulcrate Classifications: GASTROINTESTINAL AGENT; ANTIULCER Pregnancy Category: B Availability 1 g tablets; 1 g/10 mL suspension Actions A complex of aluminum hydroxide and sulfated sucrose structurally related to heparin that lacks its anticoagulant activity. Action is chemically unlike any other drug used for antiulcer therapy. Following oral administration, sucralfate and gastric acid react to form a viscous, adhesive, paste-like substance that resists further reaction with acid. This "paste" adheres to the GI mucosa with a major portion binding electrostatically to the positively charged protein molecules in the damaged mucosa of an ulcer crater or an acute gastric erosion caused by alcohol or other drugs. Therapeutic Effects Absorbs bile, inhibits the enzyme pepsin, and blocks back diffusion of H+ ions. These actions plus adherence of the paste-like complex protect damaged mucosa against further destruction from ulcerogenic secretions and drugs. Uses Short-term (up to 8 wk) treatment of duodenal ulcer. Unlabeled Uses Short-term treatment of gastric ulcer, aspirin-induced erosions, suspension for chemotherapy-induced mucositis. Contraindications Pregnancy (category B). Safety and efficacy in children are not established. Cautious Use Chronic kidney failure or dialysis due to aluminum accumulation; lactation. Route & Dosage Duodenal Ulcer Adult: PO 1 g q.i.d. 1 h a.c. and h.s. PO Maintenance 1 g b.i.d. Administration Oral Use drug solubilized in an appropriate diluent by a pharmacist when given through nasogastric tube. Administer antacids prescribed for pain relief 30 min before or after sucralfate. Separate administration of QUINOLONES, digoxin, phenytoin, tetracycline from that of sucralfate by 2 h to prevent sucralfate from binding to these compounds in the intestinal tract and reducing their bioavailability. Store in tight container at room temperature, 15°-30° C (59°-86° F). Stable for 2 y after manufacture. Adverse Effects (1%) GI: Nausea, gastric discomfort, constipation, diarrhea. Interactions Drug: May decrease absorption of QUINOLONES (e.g., ciprofloxacin, norfloxacin), digoxin, phenytoin, tetracycline. Pharmacokinetics Absorption: Minimally absorbed from GI tract (<5%). Duration: Up to 6 h (depends on contact time with ulcer crater). Elimination: 90% Excreted in feces. Nursing Implications Assessment & Drug Effects Be aware of drug interactions and schedule other medications accordingly. Patient & Family Education Although healing has occurred within the first 2 wk of therapy, treatment is usually continued 4-8 wk. Be aware that constipation is a drug-related problem. Follow these measures unless contraindicated: Increase water intake to 8-10 glasses per day; increase physical exercise, increase dietary bulk. Consult physician: a suppository or bulk laxative (e.g., Metamucil) may be prescribed. Do not breast feed while taking this drug without consulting physician.

Celecoxib

Celebrex Classifications: CENTRAL NERVOUS SYSTEM AGENT, ANALGESIC, NSAID, CYCLOOXYGENASE-2 INHIBITOR, ANTIPYRETIC Pregnancy Category: C first and second trimesters; D third trimester Availability 100 mg, 200 mg, 400 mg capsules Actions NSAID that exhibits antiinflammatory, analgesic, and antipyretic activities. Unlike ibuprofen, inhibits prostaglandin synthesis by inhibiting cyclooxygenase-2 (COX-2), but does not inhibit cyclooxygenase-1 (COX-1). Therapeutic Effects Reduces or eliminates the pain of rheumatoid and osteoarthritis. Uses Relief of S&S of osteoarthritis and rheumatoid arthritis. Treatment of acute pain and primary dysmenorrhea. Reduction of polyp formation in familial adenomatous polyposis (FAP), ankylosing spondylitis Contraindications Severe hepatic impairment; hypersensitivity to celecoxib; asthmatic patients with aspirin triad; advanced renal disease; concurrent use of diuretics and ACE inhibitors; anemia; pregnancy (category D) in third trimester; lactation. Cautious Use Patients who are P450 2C9 poor metabolizers; patients who weigh <50 kg; moderate hepatic impairment; renal insufficiency; aspirin use; prior history of GI bleeding or peptic ulcer disease; asthmatics; pregnancy (category C) in first and second trimesters, and (category D) in third trimester; elevated liver function tests; heart failure; kidney disease; hypertension; fluid retention. Route & Dosage Arthritis Adult: PO 100-200 mg b.i.d. or 200 mg q.d. Acute Pain, Dysmenorrhea Adult: PO 400 mg 1st dose, then 200 mg same day if needed, then 200 mg b.i.d. prn FAP Adult: PO 400 mg b.i.d. Administration Oral Give 2 h before/after magnesium or aluminum-containing antacids. Store in tightly closed container and protect from light. Adverse Effects (1%) Body as a Whole: Back pain, peripheral edema. Increased risk of cardiovascular events. GI: Abdominal pain, diarrhea, dyspepsia, flatulence, nausea. CNS: Dizziness, headache, insomnia. Respiratory: Pharyngitis, rhinitis, sinusitis, URI. Skin: Rash. Interactions Drug: May diminish effectiveness of ACE INHIBITORS; fluconazole increases celecoxib concentrations; may increase lithium concentrations; may increase INR in older patients on warfarin. Pharmacokinetics Peak: 3 h. Distribution: 97% protein bound; crosses placenta. Metabolism: Metabolized in liver by cytochrome P450 2C9 enzymes. Elimination: Excreted primarily in feces (57%), 27% excreted in urine. Half-Life: 11.2 h. Nursing Implications Assessment & Drug Effects Therapeutic effectiveness is indicated by relief of joint pain. Lab tests: Periodically monitor Hct and Hgb, liver functions, BUN and creatinine, and serum electrolytes. Monitor closely lithium levels when the two drugs are given concurrently. Monitor closely PT/INR when used concurrently with warfarin. Monitor for fluid retention and edema especially in those with a history of hypertension or CHF. Patient & Family Education Avoid using celecoxib during the third trimester of pregnancy. Promptly report any of the following: unexplained weight gain, edema, skin rash. Stop taking celecoxib and promptly report to physician if any of the following occurs: S&S of liver dysfunction including nausea, fatigue, lethargy, itching, jaundice, abdominal pain, and flulike symptoms; S&S of GI ulceration including black, tarry stools and upper GI distress. Do not breast feed while taking this dru

MPH

Cenestin, Enjuvia, Premarin, Progens Classifications: HORMONES & SYNTHETIC SUBSTITUTES; ESTROGENS Prototype: Estradiol Pregnancy Category: X Availability 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, 1.25 mg, 2.5 mg tablets; 25 mg injection; 0.625 mg vaginal cream Actions Short-acting estrogen mixture of conjugated estrogens including sodium estrone sulfate and sodium equilin sulfate. Therapeutic Effects Binds to intracellular receptors that stimulate DNA and RNA to synthesize proteins responsible for effects of estrogen. Uses Atrophic vaginitis, kraurosis vulvae, and abnormal bleeding (hormonal imbalance); also female hypogonadism, primary ovarian failure, vasomotor symptoms associated with menopause; to retard progression of osteoporosis and as palliative therapy of breast and prostatic carcinomas. Unlabeled Uses Postcoital contraceptive. Contraindications Breast cancer; known or suspected pregnancy (category X), lactation. Cautious Use Hypertension; gallbladder disease; diabetes mellitus; heart failure; liver or kidney dysfunction, history of thromboembolic disease. Route & Dosage Menopause, Osteoporosis, Atrophic Vaginitis, Kraurosis Vulvae Adult: PO 0.3-1.25 mg/d for 21 d each month, adjust to lowest level that gives symptom control (0.625 mg/d) IV/IM 25 mg, repeated in 6-12 h if needed Topical 2-4 g of cream/d Female Hypogonadism Adult: PO 2.5-7.5 mg/d in 1-3 divided doses for 20 d, followed by a 10 d rest period Postcoital Contraception Adult: PO 30 mg/d in divided doses for 5 consecutive days beginning within 72 h of coitus Breast Cancer Adult: PO 10 mg t.i.d. for at least 3 mo Prostatic Cancer Palliation Adult: PO 1.25-2.5 mg t.i.d. Administration Oral Give cyclically except when used for treatment of postpartum breast engorgement and for palliation of cancer. Cyclic regimen is to dose for 3 wk followed by 1 wk off. Topical Use calibrated dosage applicator dispensed with the cream. Intramuscular Reconstitute by first removing approximately 5 mL of air from the dry-powder vial, then slowly inject the supplied diluent to the vial by aiming it at the side of the vial. Gently agitate to dissolve but DO NOT SHAKE. Use within a few hours of reconstitution. Intravenous PREPARE: Direct: Reconstitute as for IM injection. ADMINISTER: Direct: Give slowly at a rate of 5 mg/min. Estrogen solution is compatible with D5W and NS and may be added to IV tubing just distal to the needle if necessary. Store ampule and reconstituted solution at 2°-8° C (38°-46° F) and protected from light; stable for 60 d. Discard precipitated or discolored solution. Adverse Effects (1%) CNS: Headache, dizziness, depression, libido changes. CV: Thromboembolic disorders, hypertension. GI: Nausea, vomiting, diarrhea, bloating, cholestatic jaundice. Urogenital: Mastodynia, spotting, changes in menstrual flow, dysmenorrhea, amenorrhea. Metabolic: Reduced carbohydrate tolerance, fluid retention. Other: Leg cramps, intolerance to contact lenses. Interactions Drug: BARBITURATES, carbamazepine, phenytoin, rifampin decrease estrogen effect by increasing its metabolism; ORAL ANTICOAGULANTS may decrease hypoprothrombinemic effects; interfere with effects of bromocriptine; may increase levels and toxicity of cyclosporine, TRICYCLIC ANTIDEPRESSANTS, theophylline; decrease effectiveness of clofibrate. Pharmacokinetics Absorption: Rapid absorption from GI tract; readily absorbed through skin and mucous membranes (including vaginal mucosa); slow absorption from IM injections. Distribution: Distributed throughout body tissues, especially in adipose tissue; crosses placenta, excreted in breast milk. Conjugated estrogens are bound primarily to albumin. Metabolism: Metabolized primarily in liver to glucuronide and sulfate conjugates of estradiol, estrone, and estriol. Elimination: Excreted in urine. Half-Life: 4-18 h. Nursing Implications Assessment & Drug Effects See additional implications under estradiol. Monitor for and report breakthrough vaginal bleeding. Assess for relief of menopausal symptoms. Lab tests: Monitor serum phosphatase levels with prostate cancer. Monitor bone density annually when used for osteoporosis prophylaxis. Patient & Family Education Be aware of importance of taking drug exactly as prescribed: Specifically, do not omit, increase, or decrease doses without advice of physician. Intravaginal administration: For self-administration, wash hands well before and after application, and avoid contact of denuded areas with the cream. Do not use tampons while on vaginal cream therapy. Notify physician promptly of adverse symptoms. Risk of blood clot formation is high with morning after pill. Know signs of thrombophlebitis (see Appendix F). Review package insert to ensure understanding of estrogen therapy. Do not breast feed while taking this drug

Tamsulosin

Flomax Classifications: AUTONOMIC NERVOUS SYSTEM AGENT; ALPHA-ADRENERGIC ANTAGONIST (SYMPATHOLYTIC AGENT) Prototype: Prazosin HCl Pregnancy Category: B Availability 0.4 mg capsules Actions Antagonist of the alpha1A-adrenergic receptors located in the prostate. Symptoms related to benign prostatic hypertrophy (BPH) are related to bladder outlet obstruction. Therapeutic Effects Blockage of alpha1A-adrenergic receptors can cause smooth muscles in the bladder outlet and the prostate gland to relax, resulting in improvement in urinary blood flow and a reduction in symptoms of BPH. Indicated by improved voiding. Uses Benign prostatic hypertrophy. Contraindications Hypersensitivity to tamsulosin; in conjunction with another alpha1A-adrenergic blocking agent; lactation, pediatric patients. Cautious Use Pregnancy (category B); history of syncope, hypotension. Route & Dosage Benign Prostatic Hypertrophy Adult: PO 0.4 mg q.d. 30 min after a meal, may increase up to 0.8 mg q.d. Administration Oral Give 30 min after the same meal each day. Instruct to swallow capsules whole; not to crush, chew, or open. If dose is interrupted for several days, reinitiate at the lowest dose, 0.4 mg. Store at 20°-25° C (68°-77° F). Adverse Effects (1%) Body as a Whole: Asthenia, back or chest pain. CNS: Headache, dizziness, insomnia. CV: Orthostatic hypotension (especially with first dose). GI: Diarrhea, nausea. Respiratory: Rhinitis, pharyngitis, increased cough, sinusitis. Urogenital: Decreased libido, abnormal ejaculation. Special Senses: Amblyopia. Interactions Drug: Cimetidine may decrease clearance of tamsulosin. Sildenafil, vardenafil, and tadalafil may enhance hypotensive effects. Pharmacokinetics Absorption: Rapidly absorbed from GI tract. >90% bioavailability. Peak: 4-5 h fasting, 6-7 h fed. Distribution: Widely distributed in body tissues, including kidney and prostate. Metabolism: Metabolized in the liver. Elimination: 76% excreted in urine. Half-Life: 14-15 h. Nursing Implications Assessment & Drug Effects Monitor for signs of orthostatic hypotension; take BP lying down, then upon standing. Report a systolic pressure drop of 15 mm Hg or a HR 15 beats upon standing. Monitor patients on warfarin therapy closely. Patient & Family Education Make position changes slowly to minimize orthostatic hypotension. Report dizziness, vertigo, or fainting to physician. Exercise caution with hazardous activities until response to drug is known. Be aware that concurrent use of cimetidine may increase the orthostatic hypotension adverse effect

Calcitrol

CALCIFEDIOL (kal-si-fe-dye'ole) Calderol Classifications: HORMONE AND SYNTHETIC SUBSTITUTE; VITAMIN D ANALOG Prototype: Calcitriol Pregnancy Category: C Availability 20 mcg, 50 mcg capsules Actions Vitamin D analog and major transport form of cholecalciferol (D3) Vitamin D analog is fat soluble. Because it is activated in the body and has regulatory effects, it is considered a hormone. Primary action leads to regulation of serum calcium, which is affected also by the activity of other vitamin D analogs (e.g., ergocalciferol), parathyroid hormone, and calcitonin. Pharmacologic effects of calcifediol are related to its intrinsic vitamin D activity as well as to the properties of active metabolites (e.g., calcitriol), which result from renal metabolism. Therapeutic Effects Helps to maintain serum calcium in patients undergoing chronic renal dialysis and effective in renal osteodystrophy and promotes healing in hepatic osteomalacia. Uses Management of metabolic bone disease and hypocalcemia associated with chronic renal failure in patients undergoing renal dialysis. Unlabeled Uses Osteopenia caused by prolonged glucocorticoid therapy and osteomalacia secondary to hepatic disease. Contraindications Hypersensitivity to vitamin D, vitamin D toxicity, hypercalcemia. Safe use of doses in excess of RDA during pregnancy (category C), lactation, and children not established. Cautious Use Patients receiving digitalis glycosides. Route & Dosage Metabolic Bone Disease in Patients With Chronic Renal Failure Adult: PO Initially 300-350 mcg/wk administered on a daily or alternate day schedule, may increase at 4-wk intervals if necessary; patients with normal calcium may only need 20 mcg q.o.d. (usual range 50-100 mcg/d or 100-200 mcg q.o.d.) Administration Oral Since calcitriol is a metabolite of vitamin D3, all sources of vitamin D are usually withheld during therapy or at least must be considered when calculating dosage. Adverse Effects (1%) Body as a Whole: Muscle or bone pain, idiosyncratic reaction (headache, nausea, vomiting, diarrhea, fever). GI: Anorexia, nausea, vomiting, dry mouth, thirst, constipation, diarrhea, abdominal cramps, metallic taste. Metabolic: Vitamin D intoxication, hypercalcemia, polyuria, hypercalciuria, hyperphosphatemia. CNS: Lethargy, headache, weakness, vertigo. Interactions Drug: THIAZIDE DIURETICS may cause hypercalcemia; may precipitate digitalis arrhythmias with digoxin. Pharmacokinetics Absorption: Readily absorbed from small intestines. Peak: 4 h. Duration: 15-20 d. Distribution: Stored chiefly in liver and fat deposits. Metabolism: Activated in kidneys. Elimination: Excreted primarily in bile and feces. Half-Life: 12-22 d. Nursing Implications Assessment & Drug Effects Lab tests: Determine baseline and periodic values for serum calcium, phosphorus, magnesium, and alkaline phosphatase. Monitor serum calcium whenever dosage adjustments are made. Measure urinary calcium and phosphorus levels q24h. Effectiveness of therapy depends on an adequate daily intake of calcium. Since dietary calcium and phosphate are difficult to control, the physician may prescribe a calcium supplement as needed. Monitor for manifestations of hypercalcemia (see Appendix F). If hypercalcemia occurs, discontinue calcifediol until serum calcium returns to normal (9-10.6 mg/dL). Report a fall in serum alkaline phosphatase as this usually signals the onset of hypercalcemia. Patient & Family Education Do not take this drug if experiencing S&S of hypercalcemia (see Appendix F), and report immediately to physician. Consult physician before taking an OTC medication. Calcium, phosphate, or magnesium-containing laxatives and antacids, mineral oil, and vitamin D preparations may increase adverse effects of calcifediol and therefore should be avoided. Note: Patients undergoing dialysis may require aluminum carbonate or hydroxide gels to bind intestinal phosphate and thus lower serum phosphate levels. Do not breast feed while taking this drug.

Sildenafil

Revatio, Viagra Classifications: IMPOTENCE AGENT; PHOSPHODIESTERASE (PDE) INHIBITOR Pregnancy Category: B Availability 20 mg, 25 mg, 50 mg, 100 mg tablets Actions Oral treatment for erectile dysfunction, whether organic or psychogenic in origin. Therapeutic Effects Enhances vasodilation effect of nitric oxide in the corpus cavernosus of the penis, thus sustaining an erection. Uses Erectile dysfunction, pulmonary arterial hypertension. Contraindications Hypersensitivity to sildenafil; concurrent administration of organic nitrates and nitroglycerin; pregnancy (category B); lactation. Not recommended for women or children. Cautious Use CAD, heart failure, MI, cardiac arrhythmias, stroke within 6 mo of starting drug; hypotension and hypertension; risk factors for CVA; aortic stenosis; anatomic deformity of the penis; sickle cell anemia, polycythemia; multiple myeloma; leukemia; active bleeding or a peptic ulcer; GERD, hiatal hernia; coagulopathy; retinitis pigmentosa; hepatic disease, hepatitis, cirrhosis; severe renal impairment (Clcr <30 mL/min); older adults; concurrent use with other medicines for penile dysfunction. Route & Dosage Erectile Dysfunction Adult: PO 50 mg 0.5-4 h before sexual activity (dose range: 25 to 100 mg once/d); max dose: 25 mg/d with itraconazole or ketoconazole; max dose: 25 mg/48 h with ritonavir Geriatric: PO 25 mg approximately 1 h before sexual activity Pulmonary Arterial Hypertension Adult: PO 20 mg t.i.d. (4-6 h apart) Hepatic or Severe Renal Impairment Adult: PO 25 mg approximately 1 h before sexual activity Administration Oral For ED: Dose 1 h prior to sexual activity (effective range is 0.5-4 h). Do not give within 24 h of taking any medication with nitrates (i.e., nitroglycerine). Store at 15°-30° C (59°-86° F) in a tightly closed container; protect from light. Adverse Effects (1%) Body as a Whole: Face edema, photosensitivity, shock, asthenia, pain, chills, fall, allergic reaction, arthritis, myalgia. CNS: Headache, dizziness, migraine, syncope, cerebral thrombosis, ataxia, neuralgia, paresthesias, tremor, vertigo, depression, insomnia, somnolence, abnormal dreams. CV: Flushing, chest pain, MI, angina, AV block, tachycardia, palpitation, hypotension, postural hypotension, cardiac arrest, sudden cardiac death, heart failure, cardiomyopathy, abnormal ECG, edema. GI: Dyspepsia, diarrhea, abdominal pain, vomiting, colitis, dysphagia, gastritis, gastroenteritis, esophagitis, stomatitis, dry mouth, abnormal liver function tests, thirst. Respiratory: Nasal congestion, asthma, dyspnea, laryngitis, pharyngitis, sinusitis, bronchitis, cough. Skin: Rash, urticaria, pruritus, sweating, exfoliative dermatitis. Urogenital: UTI. Special Senses: Abnormal vision (color changes, photosensitivity, blurred vision, sudden vision loss). Hematologic: Anemia, leukopenia. Metabolic: Gout, hyperglycemia, hyperuricemia, hypoglycemia, hypernatremia. Interactions Drug: NITRATES increase risk of serious hypotension; if used within 4 h of doxazosin, prazosin, terazosin, tamsulosin; cimetidine, erythromycin, ketoconazole, itraconazole, PROTEASE INHIBITORS increase sildenafil levels; rifampin can decrease sildenafil levels. Pharmacokinetics Absorption: Rapidly absorbed from GI tract. Peak: 30-120 min. Distribution: 96% protein bound. Metabolism: Metabolized in liver by cytochromes P450 3A4 (primary) and 2C9 (minor). Elimination: 80% excreted in feces, 12% in urine. Half-Life: 4 h. Nursing Implications Assessment & Drug Effects Monitor carefully for and immediately report S&S of cardiac distress. Patient & Family Education Do not take sildenafil within 4 h of taking doxazosin, prazosin, terazosin, or tamsulosin. Consuming a high-fat meal before taking drug may cause delay in drug action. Report to physician: Headaches, flushing, chest pain, indigestion, blurred vision, sensitivity to light, changes in color vision

Aspirin

(ACETYLSALICYLIC ACID) (as'pe-ren) Alka-Seltzer, A.S.A., Aspergum, Astrin , Bayer, Bayer Children's, Cosprin, Easprin, Ecotrin, Empirin, Entrophen , Halfprin, Measurin, Novasen , St. Joseph Children's, Supasa , Triaphen-10 , ZORprin Classifications: CENTRAL NERVOUS SYSTEM AGENT; ANALGESIC, SALICYLATE; ANTIPYRETIC; ANTIPLATELET Pregnancy Category: D Availability 81 mg chewable tablets; 325 mg, 500 mg tablets; 81 mg, 165 mg, 325 mg, 500 mg, 650 mg, 975 mg enteric-coated tablets; 650 mg, 800 mg sustained release tablets; 120 mg, 200 mg, 300 mg, 600 mg suppositories Actions Major actions appear to be associated primarily with inhibiting the formation of prostaglandins involved in the production of inflammation, pain, and fever. Antiinflammatory action: Inhibits prostaglandin synthesis. As an antiinflammatory agent, aspirin appears to be involved in enhancing antigen removal and in reducing the spread of inflammation in ground substances. These antiinflammatory actions also contribute to analgesic effects. Analgesic action: Principally peripheral with limited action in the CNS, possibly on the hypothalamus; results in relief of mild to moderate pain. Antipyretic action: In addition to inhibiting prostaglandin synthesis, aspirin lowers body temperature in fever by indirectly causing centrally mediated peripheral vasodilation and sweating. Antiplatelet action: Aspirin (but not other salicylates) powerfully inhibits platelet aggregation. High serum salicylate concentrations can impair hepatic synthesis of blood coagulation factors VII, IX, and X, possibly by inhibiting action of vitamin K. Therapeutic Effects Reduces inflammation, pain, and fever. Also inhibits platelet aggregation, reducing ability of blood to clot. Uses To relieve pain of low to moderate intensity. Also for various inflammatory conditions, such as acute rheumatic fever, Systemic Lupus, rheumatoid arthritis, osteoarthritis, bursitis, and calcific tendonitis, and to reduce fever in selected febrile conditions. Used to reduce recurrence of TIA due to fibrin platelet emboli and risk of stroke in men; to prevent recurrence of MI; as prophylaxis against MI in men with unstable angina. Unlabeled Uses As prophylactic against thromboembolism; to prevent cataract and progression of diabetic retinopathy; and to control symptoms related to gluten sensitivity. Contraindications History of hypersensitivity to salicylates including methyl salicylate (oil of wintergreen); sensitivity to other NSAIDs; patients with "aspirin triad" (aspirin sensitivity, nasal polyps, asthma); chronic rhinitis; chronic urticaria; history of GI ulceration, bleeding, or other problems; hypoprothrombinemia, vitamin K deficiency, hemophilia, or other bleeding disorders; CHF. Do not use aspirin during pregnancy (category D), especially in third trimester; lactation; or in prematures, neonates, or children under 2 y, except under advice and supervision of physician. Do not use in children or teenagers with chickenpox or influenza-like illnesses because of possible association with Reye's syndrome. Cautious Use Otic diseases; gout; children with fever accompanied by dehydration; hyperthyroidism; cardiac disease; renal or hepatic impairment; G6PD deficiency; anemia; preoperatively; Hodgkin's disease. Route & Dosage Mild to Moderate Pain, Fever Adult: PO/PR 350-650 mg q4h (max: 4 g/d) Child: PO/PR 10-15 mg/kg in 4-6 h (max: 3.6 g/d) Arthritic Conditions Adult: PO 3.6-5.4 g/d in 4-6 divided doses Child: PO 80-100 mg/kg/d in 4-6 divided doses; max 130 mg/kg/d Thromboembolic Disorders Adult: PO 81-325 mg qd TIA Prophylaxis Adult: PO 650 mg b.i.d. MI Prophylaxis Adult: PO 80-325 mg/d Administration Oral, Suppository Give with a full glass of water (240 mL), milk, food, or antacid to minimize gastric irritation. Enteric-coated tablets dissolve too quickly if administered with milk and should not be crushed or chewed. Store at 15°-30° C (59°-86° F) in airtight container and dry environment unless otherwise directed by manufacturer. Store suppositories in a cool place or refrigerate but do not freeze. Adverse Effects (1%) Body as a Whole: Hypersensitivity (urticaria, bronchospasm, anaphylactic shock (laryngeal edema). CNS: Dizziness, confusion, drowsiness. Special Senses: Tinnitus, hearing loss. GI: Nausea, vomiting, diarrhea, anorexia, heartburn, stomach pains, ulceration, occult bleeding, GI bleeding. Hematologic: Thrombocytopenia, hemolytic anemia, prolonged bleeding time. Skin: Petechiae, easy bruising, rash. Urogenital: Impaired renal function. Other: Prolonged pregnancy and labor with increased bleeding. Diagnostic Test Interference Bleeding time is prolonged 3-8 d (life of exposed platelets) following a single 325-mg (5 grains) dose of aspirin. Large doses of salicylates equivalent to 5 g or more of aspirin per day may cause prolonged prothrombin time by decreasing prothrombin production; interference with pregnancy tests (using mouse or rabbit); decreases in serum cholesterol, potassium, PBI, T3 and T4 concentrations, and an increase in T3 resin uptake. Serum uric acid may increase when plasma salicylate levels are below 10 and decrease when above 15 mg/dL using colorimetric methods. Urine 5-HIAA: aspirin may interfere with tests using fluorescent methods. Urine ketones: salicylates interfere with Gerhardt test (reaction with ferric chloride produces a reddish color that persists after boiling). Urine glucose: moderate to large doses of salicylates equivalent to an aspirin dosage 2.4 g/d may produce false-negative results with glucose oxidase methods (e.g., Clinistix, TesTape) and false-positive results with copper reduction methods (Benedict's solution, Clinitest). Urinary PSP excretion may be reduced by salicylates. Salicylates may cause urine VMA to be falsely elevated (by most tests), or reduced (by Pisano method). Salicylates may interfere with or cause false decreases in plasma theophylline levels using Schack and Waxler method. High plasma salicylate levels may cause abnormalities in liver function tests. Interactions Drug: Aminosalicylic acid increases risk of SALICYLATE toxicity. Ammonium chloride and other ACIDIFYING AGENTS decrease renal elimination and increase risk of SALICYLATE toxicity. ANTICOAGULANTS increase risk of bleeding. ORAL HYPOGLYCEMIC AGENTS increase hypoglycemic activity with aspirin doses >2 g/d. CARBONIC ANHYDRASE INHIBITORS enhance SALICYLATE toxicity. CORTICOSTEROIDS add to ulcerogenic effects. Methotrexate toxicity is increased. Low doses of SALICYLATES may antagonize uricosuric effects of probenecid and sulfinpyrazone. Herbal: Feverfew, garlic, ginger, ginkgo may increase bleeding potential. Pharmacokinetics Absorption: 80-100% absorbed (depending on formulation), primarily in stomach and upper small intestine. Peak levels: 15 min to 2 h. Distribution: Widely distributed in most body tissues; crosses placenta. Metabolism: Aspirin is hydrolyzed to salicylate in GI mucosa, plasma, and erythrocytes; salicylate is metabolized in liver. Elimination: 50% of dose is eliminated in the urine in 2-4 h (low doses) or 15-30 h (high doses). Excreted into breast milk. Half-Life: Aspirin 15-20 min; salicylate 2-18 h (dose dependent). Nursing Implications Assessment & Drug Effects Monitor for loss of tolerance to aspirin. The reaction is nonimmunologic; symptoms usually occur 15 min to 3 h after ingestion: profuse rhinorrhea, erythema, nausea, vomiting, intestinal cramps, diarrhea. Lab tests: frequent PT and IRN with concurrent anticoagulant therapy; more frequent fasting blood glucose levels with diabetes. Monitor the diabetic child carefully for need to adjust insulin dose. Children on high doses of aspirin are particularly prone to hypoglycemia (see Appendix F). Monitor for salicylate toxicity. In adults, a sensation of fullness in the ears, tinnitus, and decreased or muffled hearing are the most frequent symptoms associated with chronic salicylate overdosage. Monitor children closely because salicylate toxicity is enhanced by the dehydration that frequently accompanies fever or illness. Children tend to manifest salicylate toxicity by hyperventilation, agitation, mental confusion, or other behavioral changes, drowsiness, lethargy, sweating, and constipation. Note: Potential for toxicity is high in older adults and patients with asthma, nasal polyps, perennial vasomotor rhinitis, hay fever, or chronic urticaria. Patient & Family Education Do not give aspirin to children or teenagers with symptoms of varicella (chickenpox) or influenza-like illnesses because of association of aspirin usage with Reye's syndrome. Use enteric-coated tablets, extended release tablets, buffered aspirin, or aspirin administered with an antacid to reduce GI disturbances. Take aspirin 1-2 d before menses when prescribed for dysmenorrhea. When experiencing heavy menstrual blood loss, take another analgesic, such as acetaminophen, instead of aspirin. Discontinue aspirin therapy about 1 wk before surgery to reduce risk of bleeding. Do not use aspirin-containing gum or gargles or chew aspirin products for at least 1 wk following oral surgery. Note: Chronic use of high-dose aspirin during the last 3 mo of pregnancy can prolong pregnancy and labor, increase maternal bleeding before and after-delivery, and cause weight increase and hemorrhage in the neonate. Discontinue aspirin use with onset of ringing or buzzing in the ears, impaired hearing, dizziness, GI discomfort or bleeding, and report to physician. Do not use aspirin for self-medication of pain (adults) beyond 5 d without consulting a physician. Do not use aspirin longer than 3 d for fever (adults and children), never for fever over 38.9° C (102° F) in older adults or 39.5° C (103° F) in children and adults under 60 yrs or for recurrent fever without medical direction. Consult physician before using aspirin for any fever accompanied by rash, severe headache, stiff neck, marked irritability, or confusion (all possible symptoms of meningitis). Avoid alcohol when taking large doses of aspirin. Observe and report signs of bleeding (e.g., petechiae, ecchymoses, bleeding gums, bloody or black stools, cloudy or bloody urine). Maintain adequate fluid intake when taking repeated doses of aspirin. Avoid other medications containing aspirin unless directed by physician, because of danger of overdosing (there are more than 500 OTC aspirin-containing compounds). Do not breast feed while taking this drug.

Propylthiouracil

(PTU) (proe-pill-thye-oh-yoor'a-sill) Propyl-Thyracil Classifications: HORMONES AND SYNTHETIC SUBSTITUTES; ANTITHYROID AGENT Pregnancy Category: D Availability 50 mg tablets Actions Interferes with use of iodine and blocks synthesis of thyroxine (T4) and triiodothyronine (T3). Does not interfere with release and utilization of stored thyroid hormone; thus antithyroid action is delayed days and weeks until preformed T3 and T4 are degraded. Therapeutic Effects Drug-induced hormone reduction results in compensatory release of thyrotropin (TSH), which causes marked hyperplasia and vascularization of thyroid gland. With good adherence to drug regimen, chemical euthyroidism can be achieved 6-12 wk after start of therapy. Uses Hyperthyroidism, iodine-induced thyrotoxicosis, and hyperthyroidism associated with thyroiditis; to establish euthyroidism prior to surgery or radioactive iodine treatment; palliative control of toxic nodular goiter. Contraindications Last trimester of pregnancy (category D), lactation; concurrent administration of sulfonamides or coal tar derivatives such as aminopyrine or antipyrine. Cautious Use Infection; concomitant administration of anticoagulants or other drugs known to cause agranulocytosis; bone marrow depression; impaired liver function. Route & Dosage Hyperthyroidism Adult: PO 300-450 mg/d divided q8h, may need 600-1200 mg/d initially Geriatric: PO 150-300 mg/d divided q8h Child: PO 6-10 y, 50-150 mg/d; >10 y, 150-300 mg/d or 150 mg/m2/d Neonates: PO 5-10 mg/kg/d Thyrotoxic Crisis Adult: PO 200 mg q4-6h until full control achieved Administration Give at the same time each day with relation to meals. Food may alter drug response by changing absorption rate. If drug is being used to improve thyroid state before radioactive iodine (RAI) treatment, discontinued 3 or 4 d before treatment to prevent uptake interference. PTU therapy may be resumed if necessary 3-5 d after the RAI administration. Store drug at 15°-30° C (59°-86° F) in light resistant container. Adverse Effects (1%) CNS: Paresthesias, headache, vertigo, drowsiness, neuritis. GI: Nausea, vomiting, diarrhea, dyspepsia, loss of taste, sialoadenitis, hepatitis. Hematologic: Myelosuppression, lymphadenopathy, periarteritis, hypoprothrombinemia, thrombocytopenia, leukopenia, agranulocytosis. Metabolic: Hypothyroidism (goitrogenic): Enlarged thyroid, reduced GI motility, periorbital edema, puffy hands and feet, bradycardia, cool and pale skin, worsening of ophthalmopathy, sleepiness, fatigue, mental depression, dizziness, vertigo, sensitivity to cold, paresthesias, nocturnal muscle cramps, changes in menstrual periods, unusual weight gain. Skin: Skin rash, urticaria, pruritus, hyperpigmentation, lightening of hair color, abnormal hair loss. Body as a Whole: Drug fever, lupus-like syndrome, arthralgia, myalgia, hypersensitivity vasculitis. Diagnostic Test Interference Propylthiouracil may elevate prothrombin time and serum alkaline phosphatase, AST, ALT levels. Interactions Drug: Amiodarone, potassium iodide, sodium iodide, THYROID HORMONES can reverse efficacy. Pharmacokinetics Absorption: Rapidly absorbed from GI tract. Peak: 1-1.5 h. Distribution: Appears to concentrate in thyroid gland; crosses placenta; some distribution into breast milk. Metabolism: Rapidly metabolized to inactive metabolites. Elimination: 35% excreted in urine within 24 h. Half-Life: 1-2 h. Nursing Implications Assessment & Drug Effects Be aware that about 10% of patients with hyperthyroidism have leukopenia <4000 cells/mm3 and relative granulopenia. Observe for signs of clinical response to PTU (usually within 2 or 3 wk): Significant weight gain, reduced pulse rate, reduced serum T4. Lab tests: Baseline and periodic T3 and T4; periodic CBC with differential and platelet count. Satisfactory euthyroid state may be delayed for several months when thyroid gland is greatly enlarged. Be alert to signs of hypoprothrombinemia: Ecchymoses, purpura, petechiae, unexplained bleeding. Warn ambulatory patients to report these signs promptly. Be alert for important diagnostic signs of excess dosage: Contraction of a muscle bundle when pricked, mental depression, hard and nonpitting edema, and need for high thermostat setting and extra blankets in winter (cold intolerance). Monitor for urticaria (occurs in 3-7% of patients during weeks 2-8 of treatment). Report severe rash. Patient & Family Education Note that PTU treatment may be reinstituted if surgery fails to produce normal thyroid gland function. Be aware that thyroid hormone may be given concomitantly with PTU throughout pregnancy to prevent hypothyroidism in mother with little effect on fetus. Report severe skin rash or swelling of cervical lymph nodes. Therapy may be discontinued. Report to physician sore throat, fever, and rash immediately (most apt to occur in first few months of treatment). Drug will be discontinued and hematologic studies initiated. Avoid use of OTC drugs for asthma, or cough treatment without checking with the physician. Iodides sometimes included in such preparations are contraindicated. Learn how to take pulse accurately and check daily. Report to physician continued tachycardia. Report diarrhea, fever, irritability, listlessness, vomiting, weakness; these are signs of inadequate therapy or thyrotoxicosis. Chart weight 2 or 3 times weekly; clinical response is monitored through changes in weight and pulse. Continue monitoring and recording weight and pulse rate while in remission. Report onset of tremor, anxiety state, gradual ascending pulse rate, and loss of weight to physician (signs of hormone deficiency). Do not alter drug regimen (e.g., increase, decrease, omit doses, change dosage intervals). Check with physician about use of iodized salt and inclusion of seafood in the diet. Do not breast feed while taking this drug

metocopramide

Clopra, Emex , Maxeran , Maxolon, Reglan Classifications: GASTROINTESTINAL AGENT; PROKINETIC AGENT (GI STIMULANT) Pregnancy Category: B Availability 5 mg, 10 mg tablets; 5 mg/5 mL solution; 5 mg/mL injection Actions Potent central dopamine receptor antagonist. Structurally related to procainamide but has little antiarrhythmic or anesthetic activity. Exact mechanism of action not clear but appears to sensitize GI smooth muscle to effects of acetylcholine by direct action. Therapeutic Effects Increases resting tone of esophageal sphincter, and tone and amplitude of upper GI contractions. As a result, gastric emptying and intestinal transit are accelerated with little effect, if any, on gastric, biliary, or pancreatic secretions. Antiemetic action results from drug-induced elevation of CTZ threshold and enhanced gastric emptying. In diabetic gastroparesis, indicated by relief of anorexia, nausea, vomiting, persistent fullness after meals. Uses Management of diabetic gastric stasis (gastroparesis); to prevent nausea and vomiting associated with emetogenic cancer chemotherapy (e.g., cisplatin, dacarbazine); to facilitate intubation of small bowel; symptomatic treatment of gastroesophageal reflux. Contraindications Sensitivity or intolerance to metoclopramide; allergy to sulfiting agents; history of seizure disorders; concurrent use of drugs that can cause extrapyramidal symptoms; pheochromocytoma; mechanical GI obstruction or perforation; ileus; history of breast cancer; pregnancy (category B), lactation, children <6 y, infants, and neonates. Cautious Use CHF, cardiac disease; sulfite hypersensitivity, asthma, hypokalemia, hypertension; depression; hepatic disease, infertility, methemoglobin reductase deficiency, Parkinson's disease, kidney dysfunction; GI hemorrhage; G6PD deficiency, procainamide hypersensitivity, seizure disorder, seizures, tardive dyskinesia; children; history of intermittent porphyria. Route & Dosage Gastroesophageal Reflux Adult: PO 10-15 mg q.i.d. a.c. and h.s. Child: PO/IV/IM 0.4-0.8 mg/kg/d in 4 divided doses Diabetic Gastroparesis Adult: PO 10 mg q.i.d. a.c. and h.s. for 2-8 wk Geriatric: PO 5 mg a.c and h.s. Small-bowel Intubation, Radiologic Examination Adult: IM/IV 10 mg administered over 1-2 min Child: IM/IV <6 y, 0.1 mg/kg over 1-2 min; 6-14 y, 2.5-5 mg over 1-2 min Chemotherapy-induced Emesis Adult/Child: PO 2 mg/kg 1 h before antineoplastic administration, may repeat q2h for 3 more doses if needed IM/IV 2 mg/kg 30 min before antineoplastic administration, may repeat q2h for 2 doses, then q3h for 3 doses if needed Administration Oral Give 30 min before meals and at bedtime. Intravenous Note: Verify correct IV concentration and rate of infusion for administration to infants or children with physician. PREPARE: Direct: Doses of 10 mg or less may be given undiluted. IV Infusion: Doses >10 mg IV should be diluted in at least 50 mL of D5W, NS, D5/.45% NaCl, RL or other compatible solution. ADMINISTER: Direct: Give over 1-2 min. IV Infusion: Give over 15 min. Note: Bags of metoclopramide should be protected from light during IV infusion (use of aluminum foil or a thick cotton cover). INCOMPATIBILITIES Solution/additive: Ampicillin, calcium gluconate, cephalothin, chloramphenicol, cisplatin, erythromycin, floxacillin, fluorouracil, furosemide, methotrexate, penicillin G potassium, sodium bicarbonate, TETRACYCLINES. Y-site: Allopurinol, amphotericin B cholesteryl complex, amsacrine, cefepime, doxorubicin liposome, furosemide, propofol. Discard open ampules; do not store for future use. Store at 15°-30° C (59°-86° F) in light-resistant bottle. Tablets are stable for 3 y; solutions and injections, for 5 y. Adverse Effects (1%) CNS: Mild sedation, fatigue, restlessness, agitation, headache, insomnia, disorientation, extrapyramidal symptoms (acute dystonic type), neurologic malignant syndrome with injection. GI: Nausea, constipation, diarrhea, dry mouth, altered drug absorption. Skin: Urticarial or maculopapular rash. Body as a Whole: Glossal or periorbital edema. Hematologic: Methemoglobinemia. Endocrine: Galactorrhea, gynecomastia, amenorrhea, impotence. CV: Hypertensive crisis (rare). Diagnostic Test Interference Metoclopramide may interfere with gonadorelin test by increasing serum prolactin levels. Interactions Drug: Alcohol and other CNS DEPRESSANTS add to sedation; ANTICHOLINERGICS, OPIATE ANALGESICS may antagonize effect on GI motility; PHENOTHIAZINES may potentiate extrapyramidal symptoms; may decrease absorption of acetaminophen, aspirin, atovaquone, diazepam, digoxin, lithium, tetracycline; may antagonize the effects of amantadine, bromocriptine, levodopa, pergolide, ropinirole, pramipexole; may cause increase in extrapyramidal and dystonic reactions with PHENOTHIAZINES, THIOXANTHENES, droperidol, haloperidol, loxapine, metyrosine; may prolong neuromuscular blocking effects of succinylcholine. Pharmacokinetics Absorption: Readily absorbed from GI tract. Onset: 30-60 min PO; 10-15 min IM; 1-3 min IV. Peak: 1-2 h. Duration: 1-3 h. Distribution: Distributed to most body tissues including CNS; crosses placenta; distributed into breast milk. Metabolism: Minimally metabolized in liver. Elimination: 95% Excreted in urine, 5% in feces. Half-Life: 2.5-6 h. Nursing Implications Assessment & Drug Effects Report immediately the onset of restlessness, involuntary movements, facial grimacing, rigidity, or tremors. Extrapyramidal symptoms are most likely to occur in children, young adults, and the older adult and with high-dose treatment of vomiting associated with cancer chemotherapy. Symptoms can take months to regress. Be aware that during early treatment period, serum aldosterone may be elevated; after prolonged administration periods, it returns to pretreatment level. Lab tests: Periodic serum electrolyte. Monitor for possible hypernatremia and hypokalemia (see Appendix F), especially if patient has CHF or cirrhosis. Adverse reactions associated with increased serum prolactin concentration (galactorrhea, menstrual disorders, gynecomastia) usually disappear within a few weeks or months after drug treatment is stopped. Patient & Family Education Avoid driving and other potentially hazardous activities for a few hours after drug administration. Avoid alcohol and other CNS depressants. Report S&S of acute dystonia, such as trembling hands and facial grimacing (see Appendix F), immediately. Do not breast feed while taking this drug without consulting physician.

Diphenoxylate with Atiopine

Diphenatol, Lofene, Lomanate, Lomotil, Lonox, Lo-Trol, Low-Quel, Nor-Mil Classifications: GASTROINTESTINAL AGENT; ANTIDIARRHEAL Pregnancy Category: C Controlled Substance: Schedule V Availability 2.5 mg tablets; 2.5 mg/5 mL liquid Actions Diphenoxylate is a synthetic narcotic structurally related to meperidine. Commercially available only with atropine sulfate, added in subtherapeutic doses to discourage deliberate overdosage. Therapeutic Effects Has little or no analgesic activity or risk of dependence, except in high doses. Inhibits mucosal receptors responsible for peristaltic reflex, thereby reducing GI motility. Uses Adjunct in symptomatic management of diarrhea. Contraindications Hypersensitivity to diphenoxylate or atropine; severe dehydration or electrolyte imbalance, advanced liver disease, obstructive jaundice, diarrhea caused by pseudomembranous enterocolitis associated with use of broad-spectrum antibiotics; diarrhea associated with organisms that penetrate intestinal mucosa; diarrhea induced by poisons until toxic material is eliminated from GI tract; glaucoma; children <2 y of age. Safe use during pregnancy (category C) or lactation is not established. Cautious Use Advanced hepatic disease, abnormal liver function tests; renal function impairment, patients receiving addicting drugs, addiction-prone individuals or those whose history suggests drug abuse; ulcerative colitis; young children (particularly patients with Down syndrome). Route & Dosage Diarrhea Adult: PO 1-2 tablets or 1-2 teaspoons full (5 mL) 3-4 times/d (each tablet or 5 mL contains 2.5 mg diphenoxylate HCl and 0.025 mg atropine sulfate) Child: PO 2-12 y, 0.3-0.4 mg/kg/d of liquid in divided doses Administration Oral Crush tablet if necessary and give with fluid of patient's choice. Reduce dosage as soon as initial control of symptoms occurs. Withhold drug in presence of severe dehydration or electrolyte imbalance until appropriate corrective therapy has been initiated. Note: Treatment is generally continued for 24-36 h before it is considered ineffective. Store in tightly covered, light-resistant container, preferably 15°-30° C (59°-86° F), unless otherwise directed by manufacturer. Adverse Effects (1%) Body as a Whole: Hypersensitivity (pruritus, angioneurotic edema, giant urticaria, rash). CNS: Headache, sedation, drowsiness, dizziness, lethargy, numbness of extremities; restlessness, euphoria, mental depression, weakness, general malaise. CV: Flushing, palpitation, tachycardia. Special Senses: Nystagmus, mydriasis, blurred vision, miosis (toxicity). GI: Nausea, vomiting, anorexia, dry mouth, abdominal discomfort or distension, paralytic ileus, toxic megacolon. Other: Urinary retention, swelling of gums. Interactions Drug: MAO INHIBITORS may precipitate hypertensive crisis; alcohol and other CNS DEPRESSANTS may enhance CNS effects; also see atropine. Pharmacokinetics Absorption: Readily absorbed from GI tract. Onset: 45-60 min. Peak: 2 h. Duration: 3-4 h. Distribution: Distributed into breast milk. Metabolism: Rapidly metabolized to active and inactive metabolites in liver. Elimination: Excreted slowly through bile into feces; small amount excreted in urine. Half-Life: 4.4 h. Nursing Implications Assessment & Drug Effects Assess GI function; report abdominal distention and signs of decreased peristalsis. Monitor for S&S of dehydration (see Appendix F). It is essential to monitor young children closely; dehydration occurs more rapidly in this age group and may influence variability of response to diphenoxylate and predispose patient to delayed toxic effects. Monitor frequency and consistency of stools. Patient & Family Education Take medication only as directed by physician. Notify physician if diarrhea persists or if fever, bloody stools, palpitation, or other adverse reactions occur. Do not drive or engage in other potentially hazardous activities until response to drug is known. Do not breast feed while taking this drug without consulting physician.

Omeprazole

Prilosec, Prilosec OTC, Zegerid Classifications: GASTROINTESTINAL AGENT; PROTON PUMP INHIBITOR Pregnancy Category: C Availability 10 mg, 20 mg, 40 mg capsules; 20 mg powder for oral suspension Actions An antisecretory compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+-ATPase enzyme system [the acid (proton H+) pump] in the parietal cells. Therapeutic Effects Suppresses gastric acid secretion relieving gastrointestinal distress and promoting ulcer healing. Uses Duodenal and gastric ulcer. Gastroesophageal reflux disease including severe erosive esophagitis (4 to 8 wk treatment). Long-term treatment of pathologic hypersecretory conditions such as Zollinger-Ellison syndrome, multiple endocrine adenomas, and systemic mastocytosis. In combination with clarithromycin to treat duodenal ulcers associated with Helicobacter pylori. Unlabeled Uses Healing or prevention of NSAID-related ulcers. Contraindications Long-term use for gastroesophageal reflux disease (GERD), duodenal ulcers; proton pump inhibitors (PPIs), hypersensitivity; children <2 y; use of OTC formulation in children <18 y or GI bleeding; pregnancy (category C); use of Zegerid in metabolic alkalosis, hypocalcemia, vomiting, GI bleeding. Cautious Use Dysphagia; metabolic or respiratory alkalosis; lactation. Route & Dosage Gastroesophageal Reflux, Erosive Esophagitis, Duodenal Ulcer Adult: PO 20 mg once/d for 4-8 wk Gastric Ulcer Adult: PO 20 mg b.i.d. for 4-8 wk Hypersecretory Disease Adult: PO 60 mg once/d up to 120 mg t.i.d. Duodenal Ulcer Associated with H. pylori Adult: PO 40 mg once/d for 14 d, then 20 mg/d for 14 d, in combination with clarithromycin 500 mg t.i.d. for 14 d Administration Oral Give before food, preferably breakfast; capsules must be swallowed whole (do not open, chew, or crush). Note: Antacids may be administered with omeprazole. Adverse Effects (1%) CNS: Headache, dizziness, fatigue. GI: Diarrhea, abdominal pain, nausea, mild transient increases in liver function tests. Urogenital: Hematuria, proteinuria. Skin: Rash. Diagnostic Test Interference Omeprazole has been reported to significantly impair peak cortisol response to exogenous ACTH. This finding is undergoing further investigation. Interactions Drug: Concomitant administration of diazepam and omeprazole may increase diazepam concentrations. Concomitant administration of phenytoin and omeprazole may increase phenytoin levels. Concomitant administration of warfarin and omeprazole may increase warfarin levels. Pharmacokinetics Absorption: Poorly absorbed from GI tract; 30-40% reaches systemic circulation. Onset: 0.5-3.5 h. Peak: Peak inhibition of gastric acid secretion: 5 d. Metabolism: Metabolized in liver. Elimination: 80% excreted in urine, 20% in feces. Half-Life: 0.5-1.5 h. Nursing Implications Assessment & Drug Effects Lab tests: Monitor urinalysis for hematuria and proteinuria. Periodic liver function tests with prolonged use. Patient & Family Education Report any changes in urinary elimination such as pain or discomfort associated with urination, or blood in urine. Report severe diarrhea; drug may need to be discontinued. Do not breast feed while taking this drug.

Desmopressin Acetate

DDAVP, Stimate Classifications: HORMONES AND SYNTHETIC SUBSTITUTES; PITUITARY (ANTIDIURETIC) HORMONE Prototype: Vasopressin Pregnancy Category: B Availability 0.1 mg, 0.2 mg tablets; 0.1 mg/mL, 1.5 mg/mL nasal solution; 4 mcg/mL, 15 mcg/mL injection Actions Synthetic analog of the natural human posterior pituitary (antidiuretic) hormone, arginine vasopressin. Has more specific and longer duration of action than antidiuretic hormone and lower incidence of allergic reactions. Also, oxytocic and vasopressor actions are not apparent at therapeutic dosages. Unlike vasopressin, it does not stimulate release of adrenocorticotropic hormone nor does it increase plasma cortisol, growth hormone, prolactin, or luteinizing hormone levels. Therapeutic Effects Reduces urine volume and osmolality in patients with central diabetes insipidus by increasing reabsorption of water by kidney collecting tubules. Produces a dose-related increase in factor VIII (antihemophilic factor) and von Willebrand's factor. Uses To control and prevent symptoms and complications of central (neurohypophyseal) diabetes insipidus, and to relieve temporary polyuria and polydipsia associated with trauma or surgery in the pituitary region. Unlabeled Uses To increase factor VIII activity in selected patients with mild to moderate hemophilia A and in type I von Willebrand's disease or uremia, and to control enuresis in children. Contraindications Nephrogenic diabetes insipidus, type II B von Willebrand's disease. Safe use during pregnancy (category B) or lactation is not established. Cautious Use Coronary artery insufficiency, hypertensive cardiovascular disease. Route & Dosage Diabetes Insipidus Adult: Intranasal 0.1-0.4 mL (10-40 mcg) in 1-3 divided doses IV/SC 2-4 mcg in 2 divided doses PO 0.2-0.4 mg/d Child: Intranasal 3 mo-12 y, 0.05-0.3 mL in 1-2 divided doses IV/SC 0.3 mcg/kg infused over 15-30 min PO 0.05 mg titrated to response Enuresis Adult/Child: Intranasal 5-40 mcg h.s. Child: PO 6 y, 0.2 mg h.s., may titrate up to 0.6 mg h.s. Von Willebrand's Disease Adult/Child: IV/SC >3 mo, 0.3 mcg/kg 30 min preop, may repeat in 48 h if needed Administration Oral Note that 0.2 mg PO is equivalent to 10 mcg (0.1 mL) intranasal. Intranasal Follow manufacturer's instructions for proper technique with nasal spray. Give initial dose in the evening, and observe antidiuretic effect. Dose is increased each evening until uninterrupted sleep is obtained. If daily urine volume is more than 2 L after nocturia is controlled, morning dose is started and adjusted daily until urine volume does not exceed 1.5-2 L/24 h. Intravenous PREPARE: Direct: Give undiluted for diabetes insipidus. IV Infusion: Dilute 0.3 mcg/kg in 10 mL of NS (children 10 kg) or 50 mL of NS (children >10 kg and adults) for von Willebrand's disease (type I). ADMINISTER: Direct: Give direct IV over 30 s for diabetes insipidus. IV Infusion: Give over 15-30 min for von Willebrand's disease (type I). Store parenteral and nasal solution in refrigerator preferably at 4° C (39.2° F) unless otherwise directed. Avoid freezing. Nasal spray can be stored at room temperature. Discard solutions that are discolored or contain particulate matter. Adverse Effects (1%) All: Dose related. CNS: Transient headache, drowsiness, listlessness. Special Senses: Nasal congestion, rhinitis, nasal irritation. GI: Nausea, heartburn, mild abdominal cramps. Other: Vulval pain, shortness of breath, slight rise in BP, facial flushing, pain and swelling at injection site. Interactions Drug: Demeclocycline, lithium, other VASOPRESSORS may decrease antidiuretic response; carbamazepine, chlorpropamide, clofibrate may prolong antidiuretic response. Pharmacokinetics Absorption: 10-20% absorbed through nasal mucosa. Onset: 15-60 min. Peak: 1-5 h. Duration: 5-21 h. Distribution: Small amount crosses blood-brain barrier; distributed into breast milk. Half-Life: 76 min. Nursing Implications Assessment & Drug Effects Monitor I&O ratio and pattern (intervals). Fluid intake must be carefully controlled, particularly in older adults and the very young to avoid water retention and sodium depletion. Weigh patient daily and observe for edema. Severe water retention may require reduction in dosage and use of a diuretic. Monitor BP during dosage-regulating period and whenever drug is administered parenterally. Monitor urine and plasma osmolality. An increase in urine osmolality and a decrease in plasma osmolality indicate effectiveness of treatment in diabetes insipidus. Patient & Family Education Report upper respiratory tract infection or nasal congestion. Follow manufacturer's instructions for insertion to ensure delivery of drug high into nasal cavity and not down throat. A flexible calibrated plastic tube is provided. Do not breast feed while taking this drug without consulting physician

Haloperidol

HALOPERIDOL DECANOATE Haldol LA Classifications: CENTRAL NERVOUS SYSTEM AGENT; PSYCHOTHERAPEUTIC; ANTIPSYCHOTIC; BUTYROPHENONE Actions: Potent, long-acting butyrophenone derivative with pharmacologic actions similar to those of piperazine phenothiazines but with higher incidence of extrapyramidal effects and less hypotensive and relatively low sedative activity. Therapeutic Effects: Decreases psychotic manifestations and exerts strong antiemetic effect. Uses: Management of manifestations of psychotic disorders and for control of tics and vocal utterances of Gilles de la Tourette's syndrome; for treatment of agitated states in acute and chronic psychoses. Used for short-term treatment of hyperactive children and for severe behavior problems in children of combative, explosive hyperexcitability. Unlabeled Uses: Cancer chemotherapy as an antiemetic in doses smaller than those required for antipsychotic effects; treatment of autism; alcohol dependence; chorea. Contraindications: Parkinson's disease, parkinsonism, seizure disorders, coma; alcoholism; severe mental depression, CNS depression; thyrotoxicosis. Safe use during pregnancy (category C), lactation, or in children <3 y is not established. Cautious Use: Older adult or debilitated patients, urinary retention, glaucoma, severe cardiovascular disorders; patients receiving anticonvulsant, anticoagulant, or lithium therapy. Oral: Give with a full glass (240 mL) of water or with food or milk. Taper dosing regimen when discontinuing therapy. Abrupt termination can initiate extrapyramidal symptoms. Intramuscular Give by deep injection into a large muscle. Do not exceed 3 mL per injection site. Have patient recumbent at time of parenteral administration and for about 1 h after injection. Assess for orthostatic hypotension. . CNS: Extrapyramidal reactions: Parkinsonian symptoms, dystonia, akathisia, tardive dyskinesia (after long-term use); insomnia, restlessness, anxiety, euphoria, agitation, drowsiness, mental depression, lethargy, fatigue, weakness, tremor, ataxia, headache, confusion, vertigo; neuroleptic malignant syndrome, hyperthermia, grand mal seizures, exacerbation of psychotic symptoms. CV: Tachycardia, ECG changes, hypotension, hypertension (with overdosage). Endocrine: Menstrual irregularities, galactorrhea, lactation, gynecomastia, impotence, increased libido, hyponatremia, hyperglycemia, hypoglycemia. Special Senses: Blurred vision. Hematologic: Mild transient leukopenia, agranulocytosis (rare). GI: Dry mouth, anorexia, nausea, vomiting, constipation, diarrhea, hypersalivation. Urogenital: Urinary retention, priapism. Respiratory: Laryngospasm, bronchospasm, increased depth of respiration, bronchopneumonia, respiratory depression. Skin: Diaphoresis, maculopapular and acneiform rash, photosensitivity. Other: Cholestatic jaundice, variations in liver function tests, decreased serum cholesterol. Interactions Drug: CNS DEPRESSANTS, OPIATES, alcohol increase CNS depression; may antagonize activity of ORAL ANTICOAGULANTS; ANTICHOLINERGICS may increase intraocular pressure; methyldopa may precipitate dementia. Absorption: Well absorbed from GI tract; 60% reaches systemic circulation. Onset: 30-45 min IM. Peak: 2-6 h PO; 10-20 min IM; 6-7 d decanoate. Distribution: distributes mainly to liver with lower concentration in brain, lung, kidney, spleen, heart. Metabolism: Metabolized in liver. Elimination: 40% excreted in urine within 5 d; 15% eliminated in feces; excreted in breast milk. Half-Life: 13-35 h. Nursing Implications Assessment & Drug Effects: Monitor for therapeutic effectiveness. Because of long half-life, therapeutic effects are slow to develop in early therapy or when established dosing regimen is changed. "Therapeutic window" effect may occur after long period of high doses. Close observation is imperative when doses are changed. Target symptoms expected to decrease with successful haloperidol treatment include hallucinations, insomnia, hostility, agitation, and delusions. Monitor patient's mental status daily. Monitor for neuroleptic malignant syndrome, especially in those with hypertension or taking lithium. Symptoms of NMS can appear suddenly after initiation of therapy or after months or years of taking neuroleptic (antipsychotic) medication. Immediately discontinue drug if NMS suspected. Monitor for parkinsonism and tardive dyskinesia. Risk of tardive dyskinesia appears to be greater in women receiving high doses and in older adults. It can occur after long-term therapy and even after therapy is discontinued. Monitor for extrapyramidal (neuromuscular) reactions that occur frequently during first few days of treatment. Symptoms are usually dose related and are controlled by dosage reduction or concomitant administration of antiparkinson drugs. Be alert for behavioral changes in patients who are concurrently receiving antiparkinson drugs. Monitor for exacerbation of seizure activity. Observe patients closely for rapid mood shift to depression when haloperidol is used to control mania or cyclic disorders. Depression may represent a drug adverse effect or reversion from a manic state. Lab tests: Monitor WBC count with differential and liver function in patients on prolonged therapy. Patient & Family Education: Avoid use of alcohol during therapy. Do not drive or engage in other potentially hazardous activities until response to drug is known. Discuss oral hygiene with health care provider; dry mouth may promote dental problems. Drink adequate fluids. Avoid overexposure to sun or sunlamp and use a sunscreen; drug can cause a photosensitivity reaction. Do not breast feed while taking this drug without consulting physician

Protoxin

Protonix, Protonix IV Classifications: GASTROINTESTINAL AGENT; PROTON PUMP INHIBITOR Prototype: Omeprazole Pregnancy Category: B Availability 40 mg enteric coated tablets; 40 mg vial Actions Gastric acid pump inhibitor; belongs to a class of antisecretory compounds. Gastric acid secretion is decreased by inhibiting the H+, K+-ATPase enzyme system responsible for acid production. Therapeutic Effects Specifically, suppresses gastric acid secretion by inhibiting the acid (proton H+) pump in the parietal cells. Uses Short-term treatment of erosive esophagitis associated with gastroesophageal reflux disease (GERD). Contraindications Hypersensitivity to pantoprazole or other proton pump inhibitors (PPIs); severe hepatic insufficiency, cirrhosis. Cautious Use Mild to moderate hepatic insufficiency; pregnancy (category B), lactation. Safety and effectiveness in children <18 y are not established. Route & Dosage Erosive Esophagitis Adult: PO 40 mg q.d. times 8-16 wk IV 40 mg q.d. times 7-10 d Administration Oral Do not crush or break in half. Must be swallowed whole. Note: Therapy beyond 16 wk is not recommended. Store preferably at 20°-25° C (66°-77° F), but room temperature permitted. Intravenous PREPARE: IV Infusion: Two-min infusion: Reconstitute each 40 mg vial with 10 mL NS. Fifteen-min infusion: Reconstitute as for 2-min infusion, then further dilute with 100 mL of D5W, NS, or RL to yield 0.4 mg/mL. ADMINISTER: IV Infusion: Give through a dedicated line or flushed IV line before and after each dose with D5W, NS, or RL. Two-min infusion: Give over at least 2 min. Fifteen-min infusion: Infuse over 15 min at a rate of 6 mg/min (7 mL/min). Note: Protonix IV packaged with an in-line filter must be used with the provided filter. A newer formulation does not require an in-line filter. Reconstituted solution may be stored for up to 2 h at 15-30° C (59-86° F) before further dilution. The diluted 100 mL solution may be stored for up to 22 h. INCOMPATIBILITIES Solution/Additive: Solutions containing zinc. Y-site: Midazolam. Adverse Effects (1%) GI: Diarrhea, flatulence, abdominal pain. CNS: Headache, insomnia. Skin: Rash. Interactions Drug: May decrease absorption of ampicillin, IRON SALTS, itraconazole, ketoconazole; increases INR with warfarin. Pharmacokinetics Absorption: Well absorbed with 77% bioavailability. Peak: 2.4 h. Distribution: 98% protein bound. Metabolism: Metabolized in liver primarily by CYP2C19. Elimination: 71% excreted in urine, 18% in feces. Half-Life: 1 h. Nursing Implications Assessment & Drug Effects Monitor for and immediately report S&S of angioedema or a severe skin reaction. Lab tests: Urea breath test 4-6 wk after completion of therapy. Patient & Family Education Contact physician promptly if any of the following occur: Peeling, blistering, or loosening of skin; skin rash, hives, or itching; swelling of the face, tongue, or lips; difficulty breathing or swallowing. Do not breast feed while taking this drug without consulting physician

Midazolam

Classifications: CENTRAL NERVOUS SYSTEM AGENT; BENZODIAZEPINE ANXIOLYTIC; SEDATIVE-HYPNOTIC Prototype: Lorazepam Pregnancy Category: D Controlled Substance: Schedule IV Availability 2 mg/mL syrup; 1 mg/mL, 5 mg/mL injection Actions Short-acting parenteral benzodiazepine. Mechanism of action unclear. Intensifies activity of gamma-aminobenzoic acid (GABA), a major inhibitory neurotransmitter of the brain, by interfering with its reuptake and promoting its accumulation at neuronal synapses. This calms the patient, relaxes skeletal muscles, and in high doses produces sleep. Therapeutic Effects CNS depressant with muscle relaxant, sedative-hypnotic, anticonvulsant, and amnestic properties. Uses Sedation before general anesthesia, induction of general anesthesia; to impair memory of perioperative events (anterograde amnesia); for conscious sedation prior to short diagnostic and endoscopic procedures; and as the hypnotic supplement to nitrous oxide and oxygen (balanced anesthesia) for short surgical procedures. Contraindications Intolerance to benzodiazepines; acute narrow-angle glaucoma; shock, coma; acute alcohol intoxication; intraarterial injection. Safety in pregnancy (category D), labor and delivery, or lactation is not established. Cautious Use Patient with COPD; chronic kidney failure; CHF; the older adult. Route & Dosage Conscious Sedation Adult: IM 0.07-0.08 mg/kg 30-60 min before procedure IV 1-1.5 mg, may repeat in 2 min prn; Intubated Patients, 0.05-0.2 mg/kg/h by continuous infusion Child: IM 0.08 mg/kg times 1 dose PR 0.3 mg/kg times 1 dose; Intubated Patients, 2 mcg/kg/min by continuous infusion, may increase by 1 mcg/kg/min q30 min until light sleep is induced Neonate: IV 0.5-1 mcg/kg/min IV Induction for General Anesthesia Adult: IV Premedicated, 0.15-0.25 mg/kg over 20-30 s, allow 2 min for effect IV Nonpremedicated, 0.3-0.35 mg/kg over 20-30 s, allow 2 min for effect Child: IV 0.15 mg/kg followed by 0.05 mg/kg q2 min times 1-3 doses Status Epilepticus Child: IV Loading Dose >2 mo, 0.15 mg/kg IV Maintenance Dose 1 mcg/kg/min infusion, may titrate upward as needed q5min Preoperative Sedation Child: PO <5 y, 0.5 mg/kg; >5 y, 0.4-0.5 mg/kg Administration Intramuscular Inject IM drug deep into a large muscle mass. Intravenous PREPARE: Direct: Dilute in D5W or NS to a concentration of 0.25 mg/mL (e.g., 1 mg in 4 mL or 5 mg in 20 mL) IV Infusion: Add 5 mL of the 5 mg/mL concentration to 45 mL of D5W or NS to yield 0.5 mg/mL. ADMINISTER: Direct: Sedation, Give over 2 min; Induction of Anesthesia, Give over 20-30 sec. IV Infusion: Give at a rate based on weight. INCOMPATIBILITIES Solution/additive: Lactated Ringer's, dimenhydrinate, pentobarbital, perphenazine, prochlorperazine, ranitidine. Y-site: Albumin, amoxicillin, amoxicillin/clavulanate, amphotericin B cholesteryl complex, ampicillin, bumetanide, butorphanol, ceftazidime, cefuroxime, clonidine, dexamethasone, dimenhydrinate, floxacillin, foscarnet, fosphenytoin, furosemide, hydrocortisone, imipenem/cilastatin, methotrexate, nafcillin, omeprazole, pentobarbital, perphenazine, prochlorperazine, sodium bicarbonate, thiopental, TPN. Store at 15°-30° C (59°-86° F), therapeutic activity is retained for 2 y from date of manufacture. Adverse Effects (1%) CNS: Retrograde amnesia, headache, euphoria, drowsiness, excessive sedation, confusion. CV: Hypotension. Special Senses: Blurred vision, diplopia, nystagmus, pinpoint pupils. GI: Nausea, vomiting. Respiratory: Coughing, laryngospasm (rare), respiratory arrest. Skin: Hives, swelling, burning, pain, induration at injection site, tachypnea. Body as a Whole: Hiccups, chills, weakness. Interactions Drug: Alcohol, CNS DEPRESSANTS, ANTICONVULSANTS potentiate CNS depression; cimetidine increases midazolam plasma levels, increasing its toxicity; may decrease antiparkinsonism effects of levodopa; may increase phenytoin levels; smoking decreases sedative and antianxiety effects. Herbal: Kava-kava, valerian may potentiate sedation. Pharmacokinetics Onset: 1-5 min IV; 5-15 min IM, 20-30 min PO. Peak: 20-60 min. Duration: <2 h IV; 1-6 h IM. Distribution: Crosses blood-brain barrier and placenta. Metabolism: Metabolized in liver. Elimination: Excreted in urine. Half-Life: 1-4 h. Nursing Implications Assessment & Drug Effects Inspect insertion site for redness, pain, swelling, and other signs of extravasation during IV infusion. Monitor for hypotension, especially if the patient is premedicated with a narcotic agonist analgesic. Monitor vital signs for entire recovery period. In obese patient, half-life is prolonged during IV infusion; therefore, duration of effects is prolonged (i.e., amnesia, postoperative recovery). Be aware that overdose symptoms include somnolence, confusion, sedation, diminished reflexes, coma, and untoward effects on vital signs. Patient & Family Education Do not drive or engage in potentially hazardous activities until response to drug is known. You may feel drowsy, weak, or tired for 1-2 d after drug has been given. Be prepared for amnesia to prevent an upsetting postoperative period. Review written instructions to assure future understanding and compliance. Patient teaching during amnestic period may not be remembered. Even if dose is small and depth of amnesia is unclear, relearn information

Colazepine

Clozaril, Fazaclo Classifications: CENTRAL NERVOUS SYSTEM (CNS) AGENT; PSYCHOTHERAPEUTIC AGENT; ANTIPSYCHOTIC; ATYPICAL Pregnancy Category: B Availability 25 mg, 100 mg tablets and orally disintegrating tablets Actions Mechanism is not defined. Interferes with binding of dopamine to D1 and D2 receptors in the limbic region of brain. It binds primarily to nondopaminergic sites (e.g., alpha-adrenergic, serotonergic, and cholinergic receptors). Therapeutic Effects Utilized for treatment of schizophrenia uncontrolled by other agents. Uses Indicated only in the management of severely ill schizophrenic patients who have failed to respond to other neuroleptic agents. Unlabeled Uses Schizo-affective disorder, severe obsessive-compulsive disorder, bipolar disorder, dementia-related behavioral disorders. Contraindications Severe CNS depression, blood dyscrasia, history of bone marrow depression; patients with myeloproliferative disorders, uncontrolled epilepsy; clozapine-induced agranulocytosis, severe granulocytosis, chemotherapy, coma, leukemia, leukopenia, neutropenia, myocarditis, concurrent administration of benzodiazepines or other psychotropic drugs; renal failure, dialysis, hepatitis, jaundice; infants, lactation. Cautious Use Arrhythmias, GI disorders, narrow-angle glaucoma, hepatic and renal impairment, prostatic hypertrophy, history of seizures; patients with cardiovascular and/or pulmonary disease; cerebrovascular disease, cardiac arrhythmias, tachycardia, dehydration, neurological disease, tardive dyskinesia, previous history of agranulocytosis; surgery, glaucoma, infection, pregnancy (category B); older adults. Safety and efficacy in children have not been established. Route & Dosage Schizophrenia Adult: PO >16 y: Initiate at 25-50 mg/d and titrate to a target dose of 350-450 mg/d in 3 divided doses at 2 wk intervals, further increases can be made if necessary, max of 900 mg/d Administration Oral Drug is usually withdrawn gradually over 1-2 wk if therapy must be discontinued. Store the drug away from heat or light. Adverse Effects (1%) CV: Orthostatic hypotension, tachycardia, ECG changes, increased risk of myocarditis especially during first month of therapy, pericarditis, pericardial effusion, cardiomyopathy, heart failure, MI, mitral insufficiency. GI: Nausea, dry mouth, constipation, hypersalivation. Hematologic : Agranulocytosis. CNS: Seizures, transient fever, sedation, neuroleptic malignant syndrome (rare), dystonic reactions (rare). Metabolic: Hyperglycemia, diabetes mellitus. Urogenital: Urinary retention. Other: Increased mortality from severe hematologic, cardiovascular, and respiratory adverse effects. Interactions Drug: Alcohol and other CNS DEPRESSANTS compound depressant effects; ANTICHOLINERGIC AGENTS potentiate anticholinergic effects; ANTIHYPERTENSIVE AGENTS may potentiate hypotension. Herbal: St. John's wort and kava may increase sedation. Pharmacokinetics Absorption: Readily absorbed from GI tract. Onset: 2-4 wk. Peak: 2.5 h. Distribution: Possibly distributed into breast milk. Metabolism: Metabolized in liver. Elimination: 50% excreted in urine, 30% in feces. Half-Life: 8-12 h. Nursing Implications Assessment & Drug Effects Lab tests: Baseline WBC and absolute neutrophil count must be made before initial treatment, every week for first 6 mo, then every 2 wk for next 6 mo, then every 4 wk, and weekly for 4 wk after the drug is discontinued. Periodically monitor blood glucose. Monitor diabetics for loss of glycemic control. Monitor for seizure activity; seizure potential increases at the higher dose level. Closely monitor for recurrence of psychotic symptoms if the drug is being discontinued. Monitor cardiovascular and respiratory status, especially during the first month of therapy. Report promptly S&S of CHF and other potential cardiac problems. Monitor for development of tachycardia or hypotension, which may pose a serious risk for patients with compromised cardiovascular function. Monitor daily temperature and report fever. Transient elevation above 38° C (100.4° F), with peak incidence during first 3 wk of drug therapy, may occur. Patient & Family Education Carefully monitor blood glucose levels if diabetic. Do not engage in any hazardous activity until response to the drug is known. Drowsiness and sedation are common adverse effects. Due to the risk of agranulocytosis (see Appendix F) it is important to comply with blood test regimen. Report flulike symptoms, fever, sore throat, lethargy, malaise, or other signs of infection. Rise slowly to avoid orthostatic hypotension. Report immediately any of the following: unexplained fatigue, especially with activity; shortness of breath, sudden weight gain or edema of the lower extremities. Take drug exactly as ordered. Do not use OTC drugs or alcohol without permission of physician. Do not breast feed while taking clozapine.

Lithium

Eskalith, Eskalith CR, Lithane, Lithobid, Lithonate, Lithotabs LITHIUM CITRATE Cibalith-S Classifications: CENTRAL NERVOUS SYSTEM (CNS) AGENT; PSYCHOTHERAPEUTIC AGENT; MOOD STABILIZER Pregnancy Category: D Availability Lithium Carbonate 150 mg, 300 mg, 600 mg capsules; 300 mg, 450 mg sustained release tablets Lithium Citrate 300 mg/5 mL syrup Actions The lithium ion behaves in the body much like the sodium ion; but its exact mechanism of action is unclear. Competes with various physiologically important cations: Na+, K+, Ca++, Mg++; therefore, it affects cell membranes, body water, and neurotransmitters. At the synapse, it accelerates catecholamine destruction, inhibits the release of neurotransmitters and decreases sensitivity of postsynaptic receptors. Therapeutic Effects Inhibits neurotransmitters; decreases over-activity of receptors involved in stimulating manic states. Response evidenced by changed facial affect, improved posture, assumption of self-care, improved ability to concentrate, improved sleep pattern. Uses Control and prophylaxis of acute mania and the acute manic phase of mixed bipolar disorder. Unlabeled Uses Acute and recurrent depression (unipolar affective disorder), schizophrenic disorders, disorders of impulse control, alcohol dependence, antineoplastic drug-induced neutropenia, aplastic anemia, SIADH, cyclic neutropenia. Contraindications Significant cardiovascular or kidney disease, brain damage, severe debilitation, dehydration or sodium depletion; patients on low-salt diet or receiving diuretics; pregnancy, especially first trimester (category D), lactation, children <12 y. Cautious Use Older adults; thyroid disease; epilepsy; concomitant use with haloperidol and other antipsychotics; cardiac disease, cardiac arrhythmias, dehydration, diarrhea; older adults; fever, hyponatremia, hypothyroidism, concurrent infection; leukemia; mental status changes, organic brain syndrome, parkinsonism; psoriasis; renal disease, renal impairment; seizure disorder, sick sinus syndrome, sodium restriction, suicidal ideation, thyroid disease, urinary retention; diabetes mellitus; severe infections; urinary retention. Route & Dosage Mania Adult: PO Loading Dose 600 mg t.i.d. or 900 mg sustained-release b.i.d. or 30 mL (48 mEq) of solution t.i.d. PO Maintenance Dose 300 mg t.i.d. or q.i.d. or 15-20 mL (24-32 mEq) solution in 2-4 divided doses (max: 2.4 g/d) Child: PO 15-60 mg/kg/d in divided doses Administration Oral Give with meals. Ensure that sustained release tablets are not chewed or crushed; must be swallowed whole. Protect from light and moisture. Adverse Effects (1%) CNS: Dizziness, headache, lethargy, drowsiness, fatigue, slurred speech, psychomotor retardation, giddiness, incontinence, restlessness, seizures, confusion, blackout spells, disorientation, recent memory loss, stupor, coma, EEG changes. CV: Arrhythmias, hypotension, vasculitis, peripheral circulatory collapse, ECG changes. Special Senses: Impaired vision, transient scotomas, tinnitus. Endocrine: Diffuse thyroid enlargement, hypothyroidism, nephrogenic diabetes insipidus, transient hyperglycemia, glycosuria, hyponatremia. GI: Nausea, vomiting, anorexia, abdominal pain, diarrhea, dry mouth, metallic taste. Musculoskeletal: Fine hand tremors, coarse tremors, choreoathetotic movements; fasciculations, clonic movements, incoordination including ataxia, muscle weakness, hyperreflexia, encephalopathic syndrome (weakness, lethargy, fever, tremors, confusion, extrapyramidal symptoms). Skin: Thought to be toxicity rather than allergy: Pruritus, maculopapular rash, hyperkeratosis, chronic folliculitis, transient acneiform papules (face, neck, intertriginous areas), anesthesia of skin, cutaneous ulcers, drying and thinning of hair, allergic vasculitis. Hematologic: Reversible leukocytosis (14,000 to 18,000/mm3). Urogenital: Albuminuria, oliguria, urinary incontinence, polyuria, polydipsia, increased uric acid excretion. Body as a Whole: Edema, weight gain (common) or loss, exacerbation of psoriasis; flu-like symptoms. Interactions Drug: Carbamazepine, haloperidol, PHENOTHIAZINES increase risk of neurotoxicity, extrapyramidal effects, and tardive dyskinesias; DIURETICS, NSAIDS, methyldopa, probenecid, TETRACYCLINES decrease renal clearance of lithium, increasing pharmacologic and toxic effects; THEOPHYLLINES, urea, sodium bicarbonate, sodium or potassium citrate increase renal clearance of lithium, decreasing its pharmacologic effects. Pharmacokinetics Absorption: Readily absorbed from GI tract. Peak: 0.5-3 h carbonate; 15-60 min citrate. Distribution: Crosses blood-brain barrier and placenta; distributed into breast milk. Metabolism: Not metabolized. Elimination: 95% excreted in urine, 1% in feces, 4-5% in sweat. Half-Life: 20-27 h. Nursing Implications Assessment & Drug Effects Monitor response to drug. Usual lag of 1-2 wk precedes response to lithium therapy. Keep physician informed of progress. Lab test: Periodic lithium levels (draw blood sample prior to next dose or 8-12 h after last dose); periodic thyroid function tests. Monitor for S&S of lithium toxicity (e.g., vomiting, diarrhea, lack of coordination, drowsiness, muscular weakness, slurred speech when level is 1.5-2.0 mEq/L; ataxia, blurred vision, giddiness, tinnitus, muscle twitching, coarse tremors, polyuria when >2.0 mEq/L). Withhold one dose and call physician. Drug should not be stopped abruptly. Monitor older adults carefully to prevent toxicity, which may occur at serum levels ordinarily tolerated by other patients. Be alert to and report symptoms of hypothyroidism (see Appendix F). Weigh patient daily; check ankles, tibiae, and wrists for edema. Report changes in I&O ratio, sudden weight gain, or edema. Report early signs of extrapyramidal reactions promptly to physician. Patient & Family Education Be alert to increased output of dilute urine and persistent thirst. Dose reduction may be indicated. Contact physician if diarrhea or fever develops. Avoid practices that may encourage dehydration: hot environment, excessive caffeine beverages (diuresis). Drink plenty of liquids (2-3 L/d) during stabilization period and at least 1-1½ L/d during ongoing therapy. Avoid self-prescribed low-salt regimen, self-dosing with antacids containing sodium, and high-sodium foods (e.g., prepared meats and diet soda). Do not drive or engage in other potentially hazardous activities until response to drug is known. Lithium may impair both physical and mental ability. Use effective contraceptive measures during lithium therapy. If therapy is continued during pregnancy, serum lithium levels must be closely monitored to prevent toxicity. Do not breast feed while taking this drug.

Glargine

Lantus Classifications: HORMONES & SYNTHETIC SUBSTITUTES; ANTIDIABETIC AGENT; INSULIN Prototype: Insulin Injection Pregnancy Category: C Availability 100 U/mL injection; 3 mL cartridge Actions A recombinant human insulin analog with a long duration of action. Enhances transmembrane passage of glucose across cell membranes. Therapeutic Effects Lowers blood glucose levels over an extended period of time by stimulating peripheral glucose uptake especially in muscle and fat tissue. In addition, insulin inhibits hepatic glucose production. Uses Bedtime dosing of adults and children with type 1 diabetes, or adults with type 2 diabetes. Contraindications Prior hypersensitivity to insulin glargine; hypoglycemia. Cautious Use Renal and hepatic impairment; pregnancy (category C), lactation; safety and efficacy in children <6 y of age are not established. Route & Dosage Type 1 Diabetes Adult/Child: SC If not taking insulin, give 10 U at same time each day (usually at bedtime) once daily; if taking NPH or ultralente insulin once daily, give same dose at same time each day (usually at bedtime); if taking NPH insulin twice daily, give 80% of total daily dose at same time each day (usually at bedtime) Type 2 Diabetes Adult: SC If already taking oral hypoglycemic drugs, start with 10 U at same time each day (usually at bedtime) once daily and adjust according to patient's needs Administration Subcutaneous Do not give this product IV. Give at same time each day (usually at bedtime) and do not mix with any other insulin product. Store in refrigerator at 2°-8° C (36°-46° F), may store at room temperature, 15°-30° C (59°-86° F). Discard opened refrigerated vials after 28 d and unrefrigerated vials after 14 d. Do not expose to excessive heat or sunlight, and do not freeze. Adverse Effects (1%) Body as a Whole: Allergic reactions. Endocrine: Hypoglycemia, hypokalemia. Skin: Injection site reaction, lipodystrophy, pruritus, rash. Interactions Drug: ORAL ANTIDIABETIC AGENTS, ACE INHIBITORS, disopyramide, fluoxetine, MAO INHIBITORS, propoxyphene, SALICYLATES, SULFONAMIDE ANTIBIOTICS, octreotide may enhance hypoglycemia; CORTICOSTEROIDS, niacin, danazol, DIURETICS, SYMPATHOMIMETIC AGENTS, PHENOTHIAZINES, THYROID HORMONES, ESTROGENS, PROGESTOGENS, isoniazid, somatropin may decrease hypoglycemic effects; BETA-BLOCKERS, clonidine, lithium, alcohol may either potentiate or weaken effects of insulin; pentamidine may cause hypoglycemia followed by hyperglycemia. Herbal: Garlic, ginseng may potentiate hypoglycemic effects. Pharmacokinetics Absorption: Slowly absorbed from SC injection site. Duration: 10.4-24 h. Metabolism: Metabolized primarily in liver to active metabolites. Nursing Implications Assessment & Drug Effects Monitor for S&S of hypoglycemia (see Appendix F), especially after changes in insulin dose or type. Lab tests: Monitor fasting blood glucose and HbA1C periodically. Withhold drug and notify physician if patient is hypokalemic. Patient & Family Education Do not inject into areas with redness, swelling, itching, or dimpling. Absorption patterns for this drug are not dependent on the injection site. Ingest some form of sugar (e.g., orange juice, dissolved table sugar, honey) if symptoms of hypoglycemia develop; and seek medical assistance. Check blood sugar as prescribed; notify physician of fasting blood glucose <80 and >120 mg/dL. Notify the physician of any of the following: fever, infection, trauma, diarrhea, nausea, or vomiting. Dosage adjustment may be needed. Do not take any other medication unless approved by physician. Do not breast feed while taking this drug without consulting physician

Buproprion

Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban Classifications: CENTRAL NERVOUS SYSTEM (CNS) AGENT; ANTIDEPRESSANT Pregnancy Category: B Availability 75 mg, 100 mg tablets; 100 mg, 150 mg, 200 mg sustained-release tablets; 150 mg, 300 mg extended-release tablets Actions The neurochemical mechanism of bupropion is unknown. It does not inhibit monoamine oxidase. Compared to tricyclic antidepressants (TCA), it is a weak blocker of neural uptake of serotonin and norepinephrine. Therapeutic Effects Its antidepressive effect is related to CNS stimulant effects. Uses Indicated for mental depression; since it has been associated with increased risk of seizures, it is not the agent of first choice; adjunct for smoking cessation. Unlabeled Uses Cyclic mood disorders, schizoaffective disorders. Contraindications Hypersensitivity to bupropion; history of seizure disorder; current or prior diagnosis of bulimia or anorexia nervosa; concurrent administration of an MAO inhibitor; head trauma; CNS tumor; recent MI; abrupt discontinuation, anorexia nervosa, bulimia nervosa, children <18 y; lactation. Cautious Use Renal or hepatic function impairment; drug abuse or dependence; pregnancy (category B); cardiac disease, MI, hepatic disease, biliary cirrhosis; hypertension, bipolar disorder, mania, psychosis, diabetes mellitus, older adults, ethanol intoxication, suicidal ideation, tics, Tourette's syndrome. Route & Dosage Depression Adult: PO 75-100 mg t.i.d., start with 75 mg t.i.d., or 100 mg SR b.i.d., or 150 mg XL q.d., and increase dose q3d to 300 mg/d; doses >450 mg/d are associated with an increased risk of adverse reactions including seizures Geriatric: PO 50-100 mg/d, may increase by 50-100 mg q3-4d (max: 150 mg/dose) Smoking Cessation Adult: PO Start with 150 mg once daily x 3 d, then increase to 150 mg b.i.d. (max: 300 mg/d) for 7-12 wk Administration Oral Give with meals to decrease incidence of nausea and vomiting. Ensure that sustained-release tablets are not chewed or crushed. They must be swallowed whole. Note: Increases in dosage should not exceed 100 mg/d over a 3-d period. Greater increments increase the seizure potential. Store away from heat, direct light, and moisture. Adverse Effects (1%) Body as a Whole: Weight loss, weight gain. CNS: Seizures. The risk of seizure appears to be strongly associated with dose (especially >450 mg/d) and may be increased by predisposing factors (e.g., head trauma, CNS tumor) or a history of prior seizure; agitation, insomnia, dry mouth, blurred vision, headache, dizziness, tremor. GI: Nausea, vomiting, constipation. CV: Tachycardia. Skin: Rash. Interactions Drug: May increase metabolism of carbamazepine, cimetidine, phenytoin, phenobarbital, decreasing their effect; may increase incidence of adverse effects of levodopa, MAO INHIBITORS. Pharmacokinetics Absorption: Readily absorbed from GI tract. Onset: 3-4 wk. Peak: 1-3 h. Metabolism: Metabolized in liver (including first pass metabolism) to active metabolites. Elimination: 80% excreted in urine as inactive metabolites Half-Life: 8-24 h. Nursing Implications Assessment & Drug Effects Monitor for therapeutic effectiveness. The full antidepressant effect of drug may not be realized for 4 or more weeks. Close observation for worsening of depression or suicidal tendencies. Use extreme caution when administering drug to patient with history of seizures, cranial trauma, or other factors predisposing to seizures; during sudden and large increments in dose, seizure potential is increased. Report significant restlessness, agitation, anxiety, and insomnia. Symptoms may require treatment or discontinuation of drug. Monitor for and report delusions, hallucinations, psychotic episodes, confusion, and paranoia. Lab tests: Monitor hepatic and renal function tests while patient is taking this drug. Patient & Family Education Take drug at the same times each day. Monitor your weight at least weekly. Report significant changes in weight (+/-5 lb) to physician. Minimize or avoid alcohol because it increases the risk of seizures. Do not drive or engage in potentially hazardous activities until response to drug is known because judgment or motor and cognitive skills may be impaired. Do not abruptly discontinue drug. Gradual dosage reduction may be necessary to prevent adverse effects. Do not take any OTC drugs without consulting physician. Do not breast feed while taking this drug.

Arpiprazole

Abilify Classifications: CENTRAL NERVOUS SYSTEM (CNS) AGENT; PSYCHOTHERAPEUTIC; ANTIPSYCHOTIC; ATYPICAL Prototype: Clozapine Pregnancy Category: C Availability Actions: Exhibits high affinity for dopamine D2 and D3, serotonin 5-HT1A and 5-HT2A receptors, moderate affinity for dopamine D4, serotonin 5-HT2C and 5-HT7, alpha-1 adrenergic and histamine H1 receptors, and moderate affinity for the serotonin reuptake site. Functions as a partial agonist at the dopamine D2 and the serotonin 5-H1A receptors, and as an antagonist at serotonin 5-HT2A receptors. Therapeutic Effects: The mechanism of action is unknown. Efficacy of aripiprazole may be mediated through a combination of partial agonist activity at D2 and 5-HT1A receptors and antagonist activity at 5-HT2A receptors. Actions at other receptors may explain some other clinical effects of aripiprazole (e.g., orthostatic hypotension). Uses: Treatment of schizophrenia, bipolar mania, maintenance in bipolar 1 disorder. Unlabeled Uses: Depression with psychotic features. Contraindications: Hypersensitivity to aripiprazole; lactation; pregnancy (category C). Cautious Use: History of seizures or conditions that lower seizure threshold (e.g., Alzheimer's dementia); suicidal ideation; brain tumor; dementia; diabetes mellitus; patients with known cardiovascular disease (history of MI or ischemic heart disease, heart failure, or conduction abnormalities), cerebrovascular disease, or conditions that predispose to hypotension (dehydration, hypovolemia, and treatment with antihypertensive medications); dysphagia; ethanol intoxication; hyperglycemia, hypothermia; obesity, elderly, children. Oral: Note that dose should be reduced by 50% with concurrent treatment with ketoconazole, quinidine, fluoxetine, or paroxetine. Body as a Whole: Headache, asthenia, fever, flu-like symptoms, peripheral edema, chest pain, neck pain, neck rigidity. CNS: Anxiety, insomnia, lightheadedness, somnolence, akathisia, tremor, extrapyramidal symptoms, depression, nervousness, increased salivation, hostility, suicidal thought, manic reaction, abnormal gait, confusion, cogwheel rigidity. CV: Hypertension, tachycardia, hypotension, bradycardia. Risk of stroke in elderly with dementia-related psychosis. GI: Nausea, vomiting, constipation, anorexia. Hematologic: Ecchymosis, anemia. Metabolic: Weight gain, weight loss, hyperglycemia, diabetes mellitus, increased creatine kinase. Musculoskeletal: Muscle cramp. Respiratory: Rhinitis, cough. Skin: Rash. Special Senses: Blurred vision. Interactions Drug: Carbamazepine will decrease aripiprazole levels (may need to double aripiprazole dose); ketoconazole, quinidine, fluoxetine, paroxetine may increase aripiprazole levels (reduce dose by ½); may enhance effects of ANTIHYPERTENSIVE AGENTS. Herbal: St. John's wort may decrease aripiprazole levels. Food: High fat meals may delay time to peak plasma levels. Absorption: Well absorbed, 87% bioavailable. Peak: 3-5 h. Metabolism: Metabolized in liver by CYP3A4 and 2D6. Major metabolite, dehydroaripiprazole has some activity. Elimination: 55% excreted in feces, 25% in urine. Half-Life: 75 h (94 h for metabolite). Nursing Implications Assessment & Drug Effects: Monitor diabetics for loss of glycemic control. Monitor cardiovascular status. Assess for and report orthostatic hypotension. Take BP supine then in sitting position. Report systolic drop of >15-20 mm Hg. Patients at increased risk are those who are dehydrated, hypovolemic, or receiving concurrent antihypertensive therapy. Monitor body temperature in situations likely to elevate core temperature (e.g., exercising strenuously, exposure to extreme heat, receiving drugs with anticholinergic activity, or being subject to dehydration). Monitor for and report signs of tardive dyskinesia. Monitor for and immediately report S&S of neuroleptic malignant syndrome (NMS) that include: hyperpyrexia, muscle rigidity, altered mental status, irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia. Withhold drug if NMS is suspected. Lab tests: Monitor periodically Hct & Hgb. Monitor periodically blood glucose. Monitor for elevated CPK and myoglobinuria if NMS is suspected. Patient & Family Education Carefully monitor blood glucose levels if diabetic Do not drive or engage in other potentially hazardous activities until reaction to drug is known. Avoid situations where you are likely to become overheated or dehydrated. Notify physician if you become pregnant or intend to become pregnant while taking this drug. Do not breast feed while taking this drug

Ibuprofen

Advil, Amersol , Children's Motrin, Ibuprin, Junior Strength Motrin Caplets, Medipren, Motrin, Nuprin, Pediaprofen, Pamprin-IB, Rufen, Trendar Classifications: CENTRAL NERVOUS SYSTEM AGENT; NSAID (COX-1); ANALGESIC; ANTIPYRETIC Pregnancy Category: B Availability 100 mg, 200 mg, 400 mg, 600 mg, 800 mg tablets; 50 mg, 100 mg chewable tablets;; 100 mg/5 mL, 100 mg/2.5 mL suspension; 40 mg/mL drops Actions Prototype of the propionic acid NSAIDs (cox-1) inhibitor with nonsteroidal antiinflammatory activity and significant antipyretic and analgesic properties. Blocks prostaglandin synthesis. Ibuprofen activity also includes modulation of T-cell function, inhibition of inflammatory cell chemotaxis, decreased release of superoxide radicals, or increased scavenging of these compounds at inflammatory sites. Therapeutic Effects Has nonsteroidal antiinflammatory, analgesic, and antipyretic effects. Inhibits platelet aggregation and prolongs bleeding time but does not affect prothrombin or whole blood clotting times. Cross-sensitivity with aspirin and other nonsteroidal antiinflammatory drugs has been reported. Uses Chronic, symptomatic rheumatoid arthritis and osteoarthritis; relief of mild to moderate pain; primary dysmenorrhea; reduction of fever. Unlabeled Uses Gout, juvenile rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, vascular headache. Contraindications Patient in whom urticaria, severe rhinitis, bronchospasm, angioedema, nasal polyps are precipitated by aspirin or other NSAIDs; active peptic ulcer, bleeding abnormalities. Safe use during pregnancy (category B), lactation, or children <6 mo is not established. Cautious Use Hypertension, history of GI ulceration, impaired hepatic or renal function, chronic renal failure, cardiac decompensation, patients with SLE. Route & Dosage Inflammatory Disease Adult: PO 400-800 mg t.i.d. or q.i.d. (max: 3200 mg/d) Child: PO <20 kg, up to 400 mg/d in divided doses; 20-30 kg, up to 600 mg/d in divided doses; 30-40 kg, up to 800 mg/d in divided doses Mild to Moderate Pain, Dysmenorrhea Adult: PO 400 mg q4-6h up to 1200 mg/d Fever Adult: PO 200-400 mg t.i.d. or q.i.d. (max: 1200 mg/d) Child: PO 6 mo-12 y, 5-10 mg/kg q4-6h up to 40 mg/kg/d Administration Oral Give on an empty stomach, 1 h before or 2 h after meals. May be taken with meals or milk if GI intolerance occurs. Ensure that chewable tablets are chewed or crushed before being swallowed. Note: Tablet may be crushed if patient is unable to swallow it whole and mixed with food or liquid before swallowing. Store in tightly closed, light-resistant container unless otherwise directed by manufacturer. Adverse Effects (1%) CNS: Headache, dizziness, light-headedness, anxiety, emotional lability, fatigue, malaise, drowsiness, anxiety, confusion, depression, aseptic meningitis. CV: Hypertension, palpitation, congestive heart failure (patient with marginal cardiac function); peripheral edema. Special Senses: Amblyopia (blurred vision, decreased visual acuity, scotomas, changes in color vision); nystagmus, visual-field defects; tinnitus, impaired hearing. GI: Dry mouth, gingival ulcerations, dyspepsia, heartburn, nausea, vomiting, anorexia, diarrhea, constipation, bloating, flatulence, epigastric or abdominal discomfort or pain, GI ulceration, occult blood loss. Hematologic: Thrombocytopenia, neutropenia, hemolytic or aplastic anemia, leukopenia; decreased Hgb, Hct; transitory rise in AST, ALT, serum alkaline phosphatase; rise in (Ivy) bleeding time. GU: Acute renal failure, polyuria, azotemia, cystitis, hematuria, nephrotoxicity, decreased creatinine clearance. Skin: Maculopapular and vesicobullous skin eruptions, erythema multiforme, pruritus, rectal itching, acne. Body as a Whole: Fluid retention with edema, Stevens-Johnson syndrome, toxic hepatitis, hypersensitivity reactions, anaphylaxis, bronchospasm, serum sickness, SLE, angioedema. Interactions Drug: ORAL ANTICOAGULANTS, heparin may prolong bleeding time; may increase lithium and methotrexate toxicity. Herbal: Feverfew, garlic, ginger, ginkgo may increase bleeding potential. Pharmacokinetics Absorption: 80% absorbed from GI tract. Onset: 1 h antipyretic effect. Peak: 1-2 h. Duration: 6-8 h. Metabolism: Metabolized in liver. Elimination: Excreted primarily in urine; some biliary excretion. Half-Life: 2-4 h. Nursing Implications Assessment & Drug Effects Monitor for therapeutic effectiveness. Optimum response generally occurs within 2 wk (e.g., relief of pain, stiffness, or swelling; or improved joint flexion and strength). Observe patients with history of cardiac decompensation closely for evidence of fluid retention and edema. Lab tests: Baseline and periodic evaluations of Hgb, renal and hepatic function, and auditory and ophthalmologic examinations are recommended in patients receiving prolonged or high-dose therapy. Monitor for GI distress and S&S of GI bleeding. Note: Symptoms of acute toxicity in children include apnea, cyanosis, response only to painful stimuli, dizziness, and nystagmus. Patient & Family Education Notify physician immediately of passage of dark tarry stools, "coffee ground" emesis, frankly bloody emesis, or other GI distress, as well as blood or protein in urine, and onset of skin rash, pruritus, jaundice. Do not drive or engage in other potentially hazardous activities until response to the drug is known. Do not self-medicate with ibuprofen if taking prescribed drugs or being treated for a serious condition without consulting physician. Do not give to children younger than 3 mo or for longer than 2 d without consulting physician. Do not take aspirin concurrently with ibuprofen. Avoid alcohol and NSAIDs unless otherwise advised by physician. Concurrent use may increase risk of GI ulceration and bleeding tendencies. Do not breast feed while taking this drug without consulting physician

Allopurinol

Alloprim, Apo-allopurinol-A , Lopurin, Novopurinol A, Purinol , Zyloprim Classifications: ANTIGOUT AGENT Pregnancy Category: C Availability 100 mg, 300 mg tablets; 500 mg vial Actions Allopurinol reduces endogenous uric acid by selectively inhibiting action of xanthine oxidase, the enzyme responsible for converting hypoxanthine to xanthine and xanthine to uric acid (end product of purine catabolism). Has no analgesic, antiinflammatory, or uricosuric actions. Therapeutic Effects Thus, urate pool is decreased by the lowering of both serum and urinary uric acid levels, and hyperuricemia is prevented. Uses To control primary hyperuricemia that accompanies severe gout and to prevent possibility of flare-up of acute gouty attack; to prevent recurrent calcium oxalate stones; prophylactically to reduce severity of hyperuricemia associated with antineoplastic and radiation therapies, both of which greatly increase plasma uric acid levels by promoting nucleic acid degradation. Unlabeled Uses To reduce hyperuricemia secondary to Lesch-Nyhan syndrome, polycythemia vera, G6PD deficiency, sarcoidosis, and therapy with thiazides or ethambutol. Contraindications Hypersensitivity to allopurinol; as initial treatment for acute gouty attacks; idiopathic hemochromatosis (or those with family history); children (except those with hyperuricemia secondary to neoplastic disease and chemotherapy). Safety during pregnancy (category C) or lactation is not established. Cautious Use Impaired hepatic or renal function, history of peptic ulcer, lower GI tract disease, bone marrow depression. Route & Dosage Treatment Hyperuricemia Adult: PO 100 mg/d, may increase by 100 mg/wk (max: 800 mg/d), divide doses >300 mg/d IV 200-400 mg/m2/d (max: 600 mg/d) in 1-4 divided doses Child: PO 10 y, 10 mg/kg/d in 2-3 divided doses (max: 800 mg/d) IV 200 mg/m2/d in 1-4 divided doses Treatment Secondary Hyperuricemia Adult: PO 200-800 mg/d for 2-3 d or longer, divide doses >300 mg/d Child: PO 6-10 y, 100 mg t.i.d., <6 y, 50 mg t.i.d. Renal Impairment (based on ClCr range) Clcr: 80 mL/min = 250 mg/d; 60 mL/min = 200 mg/d; 40 mL/min = 150 mg/d; 20 mL/min = 100 mg/d; 10 mL/min = 100 mg q2d; 0 mL/min = 100 mg q3d; removed by hemodialysis. Administration Oral Give after meals for best toleration; tablet may be crushed and taken with fluid or mixed with food. Store at 15°-30° C (59°-86° F) in a tightly closed container. Intravenous PREPARE: Intermittent: • Reconstitute a single dose vial (500 mg) with 25 mL of sterile water for injection to yield 20 mg/mL.• Further dilute with NS or D5W to a concentration of 6 mg/mL.• Note: Adding 2.3 mL of diluent yields 6 mg/mL. ADMINISTER: Intermittent: Usually administered over 30-60 min. INCOMPATIBILITIES Solution/Additive: Amikacin, amphotericin B, carmustine, cefotaxime, chlorpromazine, cimetidine, clindamycin, cytarabine, dacarbazine, daunorubicin, doxycycline, droperidol, floxuridine, gentamicin, haloperidol, hydroxyzine, idarubicin, imipenem-cilastatin, mechlorethamine, meperidine, metoclopramide, methylprednisolone, minocycline, nalbuphine, netilmicin, ondansetron, prochlorperazine, promethazine, sodium bicarbonate, streptozocin, tobramycin, vinorelbine. Adverse Effects (1%) CNS: Drowsiness, headache, vertigo. GI: Nausea, vomiting, diarrhea, abdominal discomfort, indigestion, malaise. Hematologic: (Rare) Agranulocytosis, aplastic anemia, bone marrow depression, thrombocytopenia. Skin: Urticaria or pruritus, pruritic maculopapular rash, toxic epidermal necrolysis. Other: Hepatotoxicity, renal insufficiency. Diagnostic Test Interference Possibility of elevated blood levels of alkaline phosphatase and serum transaminases (AST, ALT), and decreased blood Hct, Hgb, leukocytes. Interactions Drug: Alcohol may inhibit renal excretion of uric acid; ampicillin, amoxicillin increase risk of skin rash; enhances anticoagulant effect of warfarin; toxicity from azathioprine, mercaptopurine, cyclophosphamide, cyclosporin increased; increases hypoglycemic effects of chlorpropamide; THIAZIDES increase risk of allopurinol toxicity and hypersensitivity (especially with impaired renal function); ACE INHIBITORS increase risk of hypersensitivity; high dose vitamin C increases risk of kidney stone formation. Pharmacokinetics Absorption: 80-90% absorbed from GI tract. Onset: 24-48 h. Peak: 2-6 h. Metabolism: 75-80% metabolizes to the active metabolite oxypurinol. Elimination: Slowly excreted in urine; excreted in breast milk. Half-Life: 1-3 h; oxypurinol, 18-30 h. Nursing Implications Assessment & Drug Effects Monitor for therapeutic effectiveness which is indicated by normal serum and urinary uric acid levels usually by 1-3 wk (aim of therapy is to lower serum uric acid level gradually to about 6 mg/dL), gradual decrease in size of tophi, absence of new tophaceous deposits (after approximately 6 mo), with consequent relief of joint pain and increased joint mobility. Monitor for S&S of an acute gouty attack which is most likely to occur during first 6 wk of therapy. Lab tests: Monitor serum uric acid levels q1-2wk to check adequacy of dosage. Perform baseline CBC, liver and kidney function tests before therapy is initiated and then monthly, particularly during first few months. Check urinary pH at regular intervals. Monitor patients with renal disorders more often; they tend to have a higher incidence of renal stones and drug toxicity problems. Report onset of rash or fever immediately to physician; withdraw drug. Life-threatening toxicity syndrome can occur 2-4 wk after initiation of therapy (more common with impaired renal function) and is generally accompanied by malaise, fever, and aching, a diffuse erythematous, desquamating rash, hepatic dysfunction, eosinophilia, and worsening of renal function. Patient & Family Education Drink enough fluid to produce urinary output of at least 2000 mL/d (fluid intake of at least 3000 mL/d). (Note that 1000 mL is approximately equal to 1 quart.) Report diminishing urinary output, cloudy urine, unusual color or odor to urine, pain or discomfort on urination. Report promptly the onset of itching or rash. Stop drug if a skin rash appears, even after 5 or more wk (and reportedly as long as 2 y) of therapy. Minimize exposure of eyes to ultraviolet or sunlight which may stimulate the development of cataracts. Do not drive or engage in potentially hazardous activities until response to drug is known. Remain under medical supervision while taking allopurinol (generally continued indefinitely); drug can cause severe adverse reactions. Do not breast feed while taking this drug without consulting physician

Morphine

Astramorph PF, Avinza, DepoDur, Duramorph, Epimorph , Kadian, MSIR, MS Contin, Oramorph SR, Roxanol, RMS, Statex Classifications: CENTRAL NERVOUS SYSTEM (CNS) AGENT; ANALGESIC; NARCOTIC (OPIATE) AGONIST Pregnancy Category: B (D in long-term use or high dose) Controlled Substance: Schedule II Availability 10 mg, 15 mg, 30 mg tablets/capsules; 15 mg, 20 mg, 30 mg, 60 mg, 100 mg, 120 mg, 200 mg controlled release tablets/capsules; 10 mg/2.5 mL, 10 mg/5 ml, 20 mg/mL, 20 mg/5 mL, 30 mg/1.5 mL, 100 mg/5 mL oral solution; 0.5 mg/mL, 1 mg/mL, 2 mg/mL, 4 mg/mL, 5 mg/mL, 8 mg/mL, 10 mg/mL, 15 mg/mL, 25 mg/mL, 50 mg/mL injection; 10 mg/mL, 15 mg/1.5 mL, 20 mg/2 mL extended-release lysosomal injection; 5 mg, 10 mg, 20 mg, 30 mg suppositories Actions Natural opium alkaloid with agonist activity by binding with the same receptors as endogenous opioid peptides. Narcotic agonist effects are identified with 3 types of receptors: Analgesia at supraspinal level, euphoria, respiratory depression and physical dependence; analgesia at spinal level, sedation and miosis; and dysphoric, hallucinogenic and cardiac stimulant effects. Therapeutic Effects Controls severe pain; also used as an adjunct to anesthesia. Uses Symptomatic relief of severe acute and chronic pain after nonnarcotic analgesics have failed and as preanesthetic medication; also used to relieve dyspnea of acute left ventricular failure and pulmonary edema and pain of MI. Contraindications Hypersensitivity to opiates; increased intracranial pressure; convulsive disorders; acute alcoholism; acute bronchial asthma, chronic pulmonary diseases, severe respiratory depression; chemical-irritant induced pulmonary edema; prostatic hypertrophy; diarrhea caused by poisoning until the toxic material has been eliminated; undiagnosed acute abdominal conditions; following biliary tract surgery and surgical anastomosis; pancreatitis; acute ulcerative colitis; severe liver or renal insufficiency; Addison's disease; hypothyroidism; during labor for delivery of a premature infant, in premature infants; pregnancy (category B; D in long-term use or when high dose is used); lactation. Cautious Use Toxic psychosis; cardiac arrhythmias, cardiovascular disease; emphysema; kyphoscoliosis; cor pulmonale; severe obesity; reduced blood volume; very old, very young, or debilitated patients; labor. Route & Dosage Pain Relief Adult: PO 10-30 mg q4h prn or 15-30 mg sustained release q8-12h; (Kadian) dose q12-24h, increase dose prn for pain relief; (Avinza) dose q24h IV 2.5-15 mg q4h or 0.8-10 mg/h by continuous infusion, may increase prn to control pain or 5-10 mg given epidurally q24h Epidural (DepoDur only) 10-15 mg as single dose 30 min before surgery (max: 20 mg) IM/SC 5-20 mg q4h PR 10-20 mg q4h prn Child: IV 0.05-0.1 mg/kg q4h or 0.025-2.6 mg/kg/h by continuous infusion IM/SC 0.1-0.2 mg/kg q4h (max: 15 mg/dose) PO 0.2-0.5 mg/kg q4-6h; 0.3-0.6 mg/kg sustained release q12h Neonate: IV/IM/SC 0.05 mg/kg q4-8h (max: 0.1 mg/kg) or 0.01-0.02 mg/kg/h Administration Oral Use a fixed, individualized schedule when narcotic analgesic therapy is started to provide effective management; blood levels can be maintained and peaks of pain can be prevented (usually a 4-h interval is adequate). Use lower dosage for older adult or debilitated patients than for adults. Do not break in half, crush, or allow sustained release tablet to be chewed. Do not give patient sustained release tablet within 24 h of surgery. Dilute oral solution in approximately 30 mL or more of fluid or semisolid food. A calibrated dropper comes with the bottle. Read labels carefully when using liquid preparation; available solutions: 20 mg/mL; 100 mg/mL. Intravenous Note: Verify correct IV concentration and rate of infusion/injection for administration to neonates, infants, or children with physician. PREPARE: Direct: Dilute 2-10 mg in at least 5 mL of sterile water for injection. ADMINISTER: Direct: Give a single dose over 4-5 min. Avoid rapid administration. INCOMPATIBILITIES Solution/additive: Aminophylline, amobarbital, chlorothiazide, floxacillin, fluorouracil, haloperidol, heparin, meperidine, pentobarbital, phenobarbital, phenytoin, sodium bicarbonate, thiopental. Y-site: Amphotericin B cholesteryl complex, azithromycin, cefepime, doxorubicin liposome, minocycline, sargramostim, tetracycline. Store at 15°-30° C (59°-86° F). Avoid freezing. Refrigerate suppositories. Protect all formulations from light. Adverse Effects (1%) Body as a Whole: Hypersensitivity [Pruritus, rash, urticaria, edema, hemorrhagic urticaria (rare), anaphylactoid reaction (rare)], sweating, skeletal muscle flaccidity; cold, clammy skin, hypothermia. CNS: Euphoria, insomnia, disorientation, visual disturbances, dysphoria, paradoxic CNS stimulation (restlessness, tremor, delirium, insomnia), convulsions (infants and children); decreased cough reflex, drowsiness, dizziness, deep sleep, coma, continuous intrathecal infusion may cause granulomas leading to paralysis. Special Senses: Miosis. CV: Bradycardia, palpitations, syncope; flushing of face, neck, and upper thorax; orthostatic hypotension, cardiac arrest. GI: Constipation, anorexia, dry mouth, biliary colic, nausea, vomiting, elevated transaminase levels. Urogenital: Urinary retention or urgency, dysuria, oliguria, reduced libido or potency (prolonged use). Other: Prolonged labor and respiratory depression of newborn. Hematologic: Precipitation of porphyria. Respiratory: Severe respiratory depression (as low as 2-4/min) or arrest; pulmonary edema. Diagnostic Test Interference False-positive urine glucose determinations may occur using Benedict's solution. Plasma amylase and lipase determinations may be falsely positive for 24 h after use of morphine; transaminase levels may be elevated. Interactions Drug: CNS DEPRESSANTS, SEDATIVES, BARBITURATES, BENZODIAZEPINES, and TRICYCLIC ANTIDEPRESSANTS potentiate CNS depressant effects. Use MAO INHIBITORS cautiously; they may precipitate hypertensive crisis. PHENOTHIAZINES may antagonize analgesia. Use with alcohol may lead to potentially fatal overdoses. Herbal: Kava-kava, valerian, St. John's wort may increase sedation. Pharmacokinetics Absorption: Variably absorbed from GI tract. Peak: 60 min PO; 20-60 min PR; 50-90 min SC; 30-60 min IM; 20 min IV. Duration: Up to 7 h. Distribution: Crosses blood-brain barrier and placenta; distributed in breast milk. Metabolism: Metabolized primarily in liver. Elimination: 90% of drug and metabolites excreted in urine in 24 h; 7-10% excreted in bile. Nursing Implications Assessment & Drug Effects Obtain baseline respiratory rate, depth, and rhythm and size of pupils before administering the drug. Respirations of 12/min or below and miosis are signs of toxicity. Withhold drug and report to physician. Observe patient closely to be certain pain relief is achieved. Record relief of pain and duration of analgesia. Be alert to elevated pulse or respiratory rate, restlessness, anorexia, or drawn facial expression that may indicate need for analgesia. Differentiate among restlessness as a sign of pain and the need for medication, restlessness associated with hypoxia, and restlessness caused by morphine-induced CNS stimulation (a paradoxic reaction that is particularly common in women and older adult patients). Monitor for respiratory depression; it can be severe for as long as 24 h after epidural or intrathecal administration. Monitor carefully those at risk for severe respiratory depression after epidural or intrathecal injection: Older adult or debilitated patients or those with decreased respiratory reserve (e.g., emphysema, severe obesity, kyphoscoliosis). Continue monitoring for respiratory depression for at least 24 h after each epidural or intrathecal dose. Assess vital signs at regular intervals. Morphine-induced respiratory depression may occur even with small doses, and it increases progressively with higher doses (generally max: 90 min after SC, 30 min after IM, and 7 min after IV). Encourage changes in position, deep breathing, and coughing (unless contraindicated) at regularly scheduled intervals. Narcotic analgesics also depress cough and sigh reflexes and thus may induce atelectasis, especially in postoperative patients. Be alert for nausea and orthostatic hypotension (with light-headedness and dizziness) in ambulatory patients or when a supine patient assumes the head-up position or in patients not experiencing severe pain. Monitor I&O ratio and pattern. Report oliguria or urinary retention. Morphine may dull perception of bladder stimuli; therefore, encourage the patient to void at least q4h. Palpate lower abdomen to detect bladder distention. Patient & Family Education Avoid alcohol and other CNS depressants while receiving morphine. Do not use of any OTC drug unless approved by physician. Do not smoke or ambulate without assistance after receiving drug. Bedside rails are advised. Use caution or avoid tasks requiring alertness (e.g., driving a car) until response to drug is known since morphine may cause drowsiness, dizziness, or blurred vision. Do not breast feed while taking this drug

Epoetin Alfa

Epogen, Eprex , Procrit Classifications: BLOOD FORMERS, COAGULATORS, AND ANTICOAGULANTS; HEMATOPOIETIC GROWTH FACTOR Pregnancy Category: C Availability 2000 units/mL, 3000 units/mL, 4000 units/mL, 10,000 units/mL, 20,000 units/mL Actions Glycoprotein that stimulates RBC production. Hypoxia and anemia generally increase the production of erythropoietin. Therapeutic Effects Produced in the kidney and stimulates bone marrow production of RBCs (erythropoiesis). Uses Elevates the hematocrit of patients with anemia secondary to chronic kidney failure (CRF); patients may or may not be on dialysis; other anemias related to malignancies and AIDS. Autologous blood donations for anticipated transfusions. Reduces need for blood in anemic surgical patients. Contraindications Uncontrolled hypertension and known hypersensitivity to mammalian cell-derived products and albumin (human). Cautious Use Pregnancy (category C) or lactation. Safety and effectiveness in children are not established. Route & Dosage Anemia Adult: SC/IV 3-500 U/kg/dose 3 times/wk, usually start with 50-100 U/kg/dose until target Hct range of 30-33% (max: 36%) is reached, Hct should not increase by more than 4 points in any 2-wk period, rapid increase in Hct increases the risk of serious adverse reactions (hypertension, seizures), may increase dose if Hct has not increased 5-6 points after 8 wk of therapy, reduce dose after target range is reached or the Hct increases by >4 points in any 2-wk period, dose usually increased or decreased by 25 U/kg increments Child: SC 150 U/kg/dose 3 times/wk initially, when Hct increased to 35%, decrease dose by 25 U/kg/dose until Hct reaches 40% Administration Subcutaneous Do not shake solution. Shaking may denature the glycoprotein, rendering it biologically inactive. Inspect solution for particulate matter prior to use. Do not use if solution is discolored or if it contains particulate matter. Use only one dose per vial, and do not reenter vial. Do not give with any other drug solution. Intravenous PREPARE: Direct: Give undiluted. ADMINISTER: Direct: Give direct IV as a bolus dose over 1 min. Discard any unused portion of the vial. It contains no preservatives. Store at 2°-8° C (36°-46° F). Do not freeze or shake. Adverse Effects (1%) CNS: Seizures, headache. CV: Hypertension. GI: Nausea, diarrhea. Hematologic: Iron deficiency, thrombocytosis, clotting of AV fistula. Other: Sweating, bone pain, arthralgias. Interactions Drug: No clinically significant interactions established. Pharmacokinetics Onset: 7-14 d. Metabolism: Metabolized in serum. Elimination: Minimal recovery in urine. Half-Life: 4-13 h. Nursing Implications Assessment & Drug Effects Control BP adequately prior to initiation of therapy and closely monitor and control during therapy. Hypertension is an adverse effect that must be controlled. Be aware that BP may rise during early therapy as the Hct increases. Notify physician of a rapid rise in Hct (>4 points in 2 wk). Dosage will need to be reduced because of risk of serious hypertension. Monitor for hypertensive encephalopathy in patients with CRF during period of increasing Hct. Monitor for premonitory neurological symptoms (i.e., aura, and report their appearance promptly). The potential for seizures exists during periods of rapid Hct increase (>4 points in 2 wk). Monitor closely for thrombotic events (e.g., MI, CVA, TIA), especially for patients with CRF. Lab tests: Baseline transferrin and serum ferritin. Monitor aPTT & INR closely. Patients may require additional heparin during dialysis to prevent clotting of the vascular access or artificial kidney. Determine Hct twice weekly until it is stabilized in the target range (30-33%) and the maintenance dose of epoetin alfa has been determined; then monitor at regular intervals. Perform CBC with differential and platelet count regularly. Monitor BUN, creatinine, phosphorus, and potassium regularly. Patient & Family Education Important to comply with antihypertensive medication and dietary restrictions. Do not drive or engage in other potentially hazardous activity during the first 90 d of therapy because of possible seizure activity. Note: As Hct increases, there is an improved sense of well-being and quality of life. It is important to continue compliance with dietary and dialysis prescriptions. Understand that headache is a common adverse effect. Report if severe or persistent, may indicate developing hypertension. Keep all follow-up appointments. Do not breast feed while taking this drug without consulting physician

Chlorpromazine

Ormazine, Promapar, Promaz, Sonazine, Thorazine, Thor-Prom Classifications: CENTRAL NERVOUS SYSTEM AGENT; PSYCHOTHERAPEUTIC; ANTIPSYCHOTIC; PHENOTHIAZINE; ANTIEMETIC Pregnancy Category: C Availability 10 mg, 25 mg, 50 mg, 100 mg, 200 mg tablets; 30 mg, 75 mg, 150 mg sustained-release capsules; 10 mg/5 mL syrup; 30 mg/mL, 100 mg/mL oral concentrate; 25 mg, 100 mg suppositories; 25 mg/mL injection Actions Phenothiazine derivative with actions at all levels of CNS with a mechanism that produces strong antipsychotic effects. Actions on hypothalamus and reticular formation produce strong sedation, hypotension, and depressed temperature regulation. Has strong alpha-adrenergic blocking action and weak anticholinergic effects. Directly depresses the heart; may increase coronary blood flow. Exerts quinidine-like antiarrhythmic action. Antiemetic effect due to suppression of the chemoreceptor trigger zone (CTZ). Inhibitory effect on dopamine reuptake may be the basis for moderate extrapyramidal symptoms. Antipsychotic drugs are sometimes called neuroleptics because they tend to reduce initiative and interest in the environment, decrease displays of emotions or affect, suppress spontaneous movements and complex behavior, and decrease psychotic symptoms. Spinal reflexes and unconditioned nociceptive-avoidance behaviors remain intact. Therapeutic Effects Mechanism that produces strong antipsychotic effects is unclear, but thought to be related to blockade of postsynaptic dopamine receptors in the brain. Also has antiemetic effects due to its action on the CTZ. Uses To control manic phase of manic-depressive illness, for symptomatic management of psychotic disorders, including schizophrenia, in management of severe nausea and vomiting, to control excessive anxiety and agitation before surgery, and for treatment of severe behavior problems in children, e.g., attention deficit disorder. Also used for treatment of acute intermittent porphyria, intractable hiccups, and as adjunct in treatment of tetanus. Contraindications Hypersensitivity to phenothiazine derivatives; withdrawal states from alcohol; comatose states, brain damage, bone marrow depression, Reye's syndrome; children <6 mo; pregnancy (category C), lactation. Cautious Use Agitated states accompanied by depression, seizure disorders, respiratory impairment due to infection or COPD; glaucoma, diabetes, hypertensive disease, peptic ulcer, prostatic hypertrophy; thyroid, cardiovascular, and hepatic disorders; patients exposed to extreme heat or organophosphate insecticides; previously detected breast cancer. Route & Dosage Psychotic Disorders, Agitation Adult: PO 25-100 mg t.i.d. or q.i.d., may need up to 1000 mg/d. IM/IV 25-50 mg up to 600 mg q4-6h Child: PO >6 mo, 0.55 mg/kg q4-6h prn up to 500 mg/d PR >6 mo, 1.1 mg/kg q6-8h IM/IV >6 mo, 0.55 mg/kg q6-8h Nausea and Vomiting Adult: PO 10-25 mg q4-6h prn. PR 50-100 mg q6-8h IM/IV 25-50 mg q3-4h prn Child: PO >6 mo, 0.55 mg/kg q4-6h prn up to 500 mg/d PR >6 mo, 1.1 mg/kg q6-8h IM/IV >6 mo, 0.55 mg/kg q6-8h Dementia Geriatric: PO Initial 10-25 mg 1-2 times/d, may increase q4-7d by 10-25 mg/d (max: 800 mg/d) Intractable Hiccups Adult: PO/IM/IV 25-50 mg t.i.d. or q.i.d. Administration Oral Give with food or a full glass of fluid to minimize GI distress. Ensure that oral drug is swallowed and not hoarded. Suicide attempt is a constant possibility in depressed patients, particularly when they are improving. Mix chlorpromazine concentrate just before administration in at least ½ glass juice, milk, water, coffee, tea, carbonated beverage, or with semisolid food. Ensure that sustained-release form of drug is not chewed or crushed. It must be swallowed whole. Intramuscular/Intravenous Avoid parenteral drug contact with skin, eyes, and clothing because of its potential for causing contact dermatitis. Keep patient recumbent for at least ½ h after parenteral administration. Observe closely. Report hypotensive reactions. Intramuscular Inject IM preparations slowly and deep into upper outer quadrant of buttock. Avoid SC injection; it may cause tissue irritation and nodule formation. If irritation is a problem, consult physician about diluting medication with normal saline or 2% procaine. Rotate injection sites. Intravenous PREPARE: Direct: Dilute 25 mg with 24 mL of NS to yield 1 mg/mL. Continuous: May be further diluted in up to 1000 mL of NS. ADMINISTER: Direct: Administer 1 mg or fraction thereof over 1 min for adults and over 2 min for children. Continuous: Give slowly at a rate not to exceed 1 mg/min. INCOMPATIBILITIES Solution/additive: Aminophylline, amphotericin B, ampicillin, chloramphenicol, chlorothiazide, cimetidine, dimenhydrinate, furosemide, heparin, methohexital, penicillin G, pentobarbital, phenobarbital, thiopental. Y-site: Allopurinol, amifostine, aminophylline, amphotericin B; cholesteryl complex, aztreonam, cefepime, chloramphenicol, chlorothiazide, etoposide, fludarabine, melphalan, methotrexate, paclitaxel, piperacillin/tazobactam, remifentanil, sargramostim. Lemon yellow color of parenteral preparation does not alter potency; if otherwise colored or markedly discolored, solution should be discarded. All forms are stored preferably between 15°-30° C (59°-86° F) protected from light, unless otherwise specified by the manufacturer. Avoid freezing. Adverse Effects (1%) Body as a Whole: Idiopathic edema, muscle necrosis (following IM), SLE-like syndrome, sudden unexplained death. CV: Orthostatic hypotension, palpitation, tachycardia, ECG changes (usually reversible): prolonged QT and PR intervals, blunting of T waves, ST depression. GI: Dry mouth; constipation, adynamic ileus, cholestatic jaundice, aggravation of peptic ulcer, dyspepsia, increased appetite. Hematologic: Agranulocytosis, thrombocytopenic purpura, pancytopenia (rare). Metabolic: Weight gain, hypoglycemia, hyperglycemia, glycosuria (high doses), enlargement of parotid glands. CNS: Sedation, drowsiness, dizziness, restlessness, neuroleptic malignant syndrome, tardive dyskinesias, tumor, syncope, headache, weakness, insomnia, reduced REM sleep, bizarre dreams, cerebral edema, convulsive seizures, hypothermia, inability to sweat, depressed cough reflex, extrapyramidal symptoms, EEG changes. Respiratory: Laryngospasm. Skin: Fixed-drug eruption, urticaria, reduced perspiration, contact dermatitis, exfoliative dermatitis, photosensitivity, eczema, anaphylactoid reactions, hypersensitivity vasculitis; hirsutism (long-term therapy). Special Senses: Blurred vision, lenticular opacities, mydriasis, photophobia. Urogenital: Anovulation, infertility, pseudopregnancy, menstrual irregularity, gynecomastia, galactorrhea, priapism, inhibition of ejaculation, reduced libido, urinary retention and frequency. Diagnostic Test Interference Chlorpromazine (phenothiazines) may increase cephalin flocculation, and possibly other liver function tests; also may increase PBI. False-positive result may occur for amylase, 5-hydroxyindole acetic acid, porphobilinogens, urobilinogen (Ehrlich's reagent), and urine bilirubin (Bili-Labstix). False-positive or false-negative pregnancy test results possibly caused by a metabolite of phenothiazines, which discolors urine depending on test used. Interactions Drug: Alcohol, CNS DEPRESSANTS increase CNS depression; ANTACIDS, ANTIDIARRHEALS decrease absorption—space administration 2 h before or after administration of chlorpromazine; phenobarbital increases metabolism of phenothiazine; GENERAL ANESTHETICS increase excitation and hypotension; antagonizes antihypertensive action of guanethidine; phenylpropanolamine poses possibility of sudden death; TRICYCLIC ANTIDEPRESSANTS intensify hypotensive and anticholinergic effects; ANTICONVULSANTS decrease seizure threshold—may need to increase anticonvulsant dose. Herbal: Kava-kava increased risk and severity of dystonic reaction. Pharmacokinetics Absorption: Rapid absorption with considerable first pass metabolism in liver; rapid absorption after IM. Onset: 30-60 min. Peak: 2-4 h PO; 15-20 min IM. Duration: 4-6 h. Distribution: Widely distributed; accumulates in brain; crosses placenta. Metabolism: Metabolized in liver. Elimination: Excreted in urine as metabolites; excreted in breast milk. Half-Life: Biphasic 2 and 30 h. Nursing Implications Assessment & Drug Effects Establish baseline BP (in standing and recumbent positions), and pulse, before initiating treatment. Monitor BP frequently. Hypotensive reactions, dizziness, and sedation are common during early therapy, particularly in patients on high doses and in the older adult receiving parenteral doses. Patients usually develop tolerance to these adverse effects; however, lower doses or longer intervals between doses may be required. Lab tests: Periodic CBC with differential, liver function tests, urinalysis, and blood glucose. Monitor cardiac status with baseline ECG in patients with preexisting cardiovascular disease. Be alert for signs of neuroleptic malignant syndrome (see Appendix G). Report immediately. Observe and record smoking since it increases metabolism of phenothiazines, resulting in shortened half-life and more rapid clearance of drug. Higher dosage in smokers may be required. Advise patient to stop or at least reduce smoking, if possible. Monitor I&O ratio and pattern: Urinary retention due to mental depression and compromised renal function may occur. If serum creatinine becomes elevated, therapy should be discontinued. Monitor for antiemetic effect of chlorpromazine, which may obscure signs of overdosage of other drugs or other causes of nausea and vomiting. Be alert to complaints of diminished visual acuity, reduced night vision, photophobia, and a perceived brownish discoloration of objects. Patient may be more comfortable with dark glasses. Monitor diabetics or prediabetics on long-term, high-dose therapy for reduced glucose tolerance and loss of diabetes control. Ocular examinations, and EEG (in patients >50 y) are recommended before and periodically during prolonged therapy. Patient & Family Education Take medication as prescribed and keep appointments for follow-up evaluation of dosage regimen. Improvement may not be experienced until 7 or 8 wk into therapy. Do not alter dosing regimen, and do not give the drug to another person. May cause pink to red-brown discoloration of urine. Wear protective clothing and sunscreen lotion with SPF above 12 when outdoors, even on dark days. Photosensitivity associated with chlorpromazine therapy is a phototoxic reaction. Severity of response depends on amount of exposure and drug dose. Exposed skin areas have appearance of an exaggerated sunburn. If reaction occurs, report to physician. Practice meticulous oral hygiene. Oral candidiasis occurs frequently in patients receiving phenothiazines. Report extrapyramidal symptoms that occur most often in patients on high dosage, the pediatric patient with severe dehydration and acute infection, the older adult, and women. Avoid driving a car or undertaking activities requiring precision and mental alertness until drug response is known. Do not abruptly stop this drug. Abrupt withdrawal of drug or deliberate dose skipping, especially after prolonged therapy with large doses, can cause onset of extrapyramidal symptoms (see Appendix F) and severe GI disturbances. When drug is to be discontinued, dosage must be tapered off gradually over a period of several weeks. Do not breast feed while taking this drug.

Rantidine

Zantac, Zantac EFFERdose, Zantac GELdose, Zantac-75 Classifications: GASTROINTESTINAL AGENT; ANTISECRETORY (H2-RECEPTOR ANTAGONIST) Prototype: Cimetidine Pregnancy Category: B Availability 75 mg, 150 mg, 300 mg tablets; 25 mg, 150 mg effervescent tablets; 150 mg, 300 mg capsules; 15 mg/mL syrup; 0.5 mg/mL, 25 mg/mL injection Actions Potent anti-ulcer drug that competitively and reversibly inhibits histamine action at H2-receptor sites on parietal cells, thus blocking gastric acid secretion. Indirectly reduces pepsin secretion but appears to have minimal effect on fasting and postprandial serum gastrin concentrations or secretion of gastric intrinsic factor or mucus. Therapeutic Effects Blocks daytime and nocturnal basal gastric acid secretion stimulated by histamine and reduces gastric acid release in response to food, pentagastrin, and insulin. Shown to inhibit 50% of the stimulated gastric acid secretion. Uses Short-term treatment of active duodenal ulcer; maintenance therapy for duodenal ulcer patient after healing of acute ulcer; treatment of gastroesophageal reflux disease; short-term treatment of active, benign gastric ulcer; treatment of pathologic GI hypersecretory conditions (e.g., Zollinger-Ellison syndrome, systemic mastocytosis, and postoperative hypersecretion); heartburn. Contraindications Hypersensitivity to ranitidine; acute porphyria; OTC administration in children <12 y. Cautious Use Hypersensitivity to H2-blockers; hepatic and renal dysfunction; renal failure; PKU; pregnancy (category B), infants <1 mo, lactation. Route & Dosage Duodenal Ulcer, Gastric Ulcer, Gastroesophageal Reflux Adult: PO 150 mg b.i.d. or 300 mg h.s. IV 50 mg q6-8h; 150-300 mg/24 h by continuous infusion Child: PO 4-5 mg/kg/d divided q8-12h (max: 6 mg/kg/d or 300 mg/d) IM/IV 2-4 mg/kg/d divided q6-8h; 0.1-0.125 mg/kg/h by continuous infusion Infant: PO <2 wk, 2 mg/kg/d divided q12h IV 1.5 mg/kg/d divided q12h or 0.04 mg/kg/h by continuous infusion Duodenal Ulcer, Maintenance Therapy Adult: PO 150 mg h.s. Pathologic Hypersecretory Conditions Adult: PO 150 mg b.i.d. up to 6.3 g/d IV 50 mg q6-8h Heartburn Adult: PO 75-150 mg b.i.d. Administration Oral Give with or without food; simultaneous administration does not appear to reduce absorption or serum concentrations. Administer adjunctive antacid treatment 2 h before or after drug. Store tablets in light-resistant, tightly capped container at 15°-30° C (59°-86° F) in a dry place. Intramuscular Note: Does not need to be diluted. Intravenous Note: Verify correct IV concentration and rate of infusion for infants and children with physician. PREPARE: Direct: Dilute 50 mg NS, D5W, RL, or other compatible IV solution to a total volume of 20 mL. Intermittent: Dilute 50 mg in 50-100 mL of NS, D5W, RL, or other compatible IV solution. Continuous: Dilute total daily dose in 250 mL of NS, D5W, RL, or other compatible IV solution. Final concentration should be 2.5 mg/mL. ADMINISTER: Direct: Give at a rate of 4 mL/min or 20 mL over not less than 5 min. Intermittent: Give over 15-30 min. Continuous: Give over 24 h. INCOMPATIBILITIES Solution/additive: Amphotericin B, atracurium, cefamandole, cefazolin, cefoxitin, ceftazidime, cefuroxime, clindamycin, chlorpromazine, diazepam, ethacrynic acid, hydroxyzine, methotrimeprazine, midazolam, nalbuphine, pentobarbital, phenobarbital, phytonadione OPIUM ALKALOIDS, phenobarbital. Y-site: Amphotericin B cholesteryl complex, methotrimeprazine, midazolam, OPIUM ALKALOIDS, phenobarbital. Schedule dose to coincide with end of treatment if patient is having hemodialysis. Adverse Effects (1%) CNS: Headache, malaise, dizziness, somnolence, insomnia, vertigo, mental confusion, agitation, depression, hallucinations in older adults. CV: Bradycardia (with rapid IV push). GI: Constipation, nausea, abdominal pain, diarrhea. Skin: Rash. Hematologic: Reversible decrease in WBC count, thrombocytopenia. Body as a Whole: Hypersensitivity reactions, anaphylaxis (rare). Diagnostic Test Interference Ranitidine may produce slight elevations in serum creatinine (without concurrent increase in BUN); (rare) increases in AST, ALT, alkaline phosphatase, LDH, and total bilirubin. Produces false-positive tests for urine protein with Multistix (use sulfosalicylic acid instead). Interactions Drug: may reduce absorption of cefpodoxime, cefuroxime, delavirdine, ketoconazole, itraconazole. Pharmacokinetics Absorption: Incompletely absorbed from GI tract (50% reaches systemic circulation). Peak: 2-3 h PO. Duration: 8-12 h. Distribution: Distributed into breast milk. Metabolism: Metabolized in liver. Elimination: Excreted in urine, with some excreted in feces. Half-Life: 2-3 h. Nursing Implications Assessment & Drug Effects Potential toxicity results from decreased clearance (elimination) and therefore prolonged action; greatest in the older adult patients or those with hepatic or renal dysfunction. Lab tests: Periodic liver functions. Monitor creatinine clearance if renal dysfunction is present or suspected. When clearance is <50 mL/min, manufacturer recommends reduction of the dose to 150 mg once q24h with cautious and gradual reduction of the interval to q12h or less, if necessary. Be alert for early signs of hepatotoxicity (though low and thought to be a hypersensitivity reaction): jaundice (dark urine, pruritus, yellow sclera and skin), elevated transaminases (especially ALT) and LDH. Long-term therapy may lead to vitamin B12 deficiency. Patient & Family Education Note: Long duration of action provides ulcer pain relief that is maintained through the night as well as the day. Be aware that even if symptomatic relief is provided by ranitidine, this should not be interpreted as absence of gastric malignancy. Follow-up examinations will be scheduled after therapy is discontinued. Adhere to scheduled periodic laboratory checkups during ranitidine treatment. Do not supplement therapy with OTC remedies for gastric distress or pain without physician's advice (e.g., Mylanta II reduces ranitidine absorption). Do not smoke; research shows smoking decreases ranitidine efficacy and adversely affects ulcer healing. Do not breast feed while taking this drug without consulting physician.

Filgrastim

Neupogen Classifications: BLOOD FORMERS, COAGULATORS, AND ANTICOAGULANTS; HEMATOPOIETIC GROWTH FACTOR Prototype: Epoetin alfa Pregnancy Category: C Availability 300 mcg/mL injection Actions Human granulocyte colony-stimulating factor (G-CSF) produced by recombinant DNA technology. Endogenous G-CSF regulates the production of neutrophils within the bone marrow; not species specific and primarily affects neutrophil proliferation, differentiation and selected end-cell functional activity (including enhanced phagocytic activity, antibody-dependent killing, and the increased expression of some functions associated with cell-surface antigens). Therapeutic Effects Increases neutrophil proliferation and differentiation within the bone marrow. Uses To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anticancer drugs associated with a significant incidence of severe neutropenia with fever; to decrease neutropenia associated with bone marrow transplant; to treat chronic neutropenia; to mobilize peripheral blood stem cells (PBSCs) for autologous transplantation. Contraindications Hypersensitivity to Escherichia coli-derived proteins, simultaneous administration with chemotherapy, and myeloid cancers. Cautious Use Pregnancy (category C), lactation. Route & Dosage Neutropenia Adult/Child: IV 5 mcg/kg/d by 30 min infusion, may increase by 5 mcg/kg/d (max: 30 mcg/kg/d) SC 5 mcg/kg/d as single dose, may increase by 5 mcg/kg/d (max: 20 mcg/kg/d) Administration Subcutaneous & Intravenous Do not administer filgrastim 24 h before or after cytotoxic chemotherapy. Use only one dose per vial; do not reenter the vial. Prior to injection, filgrastim may be allowed to reach room temperature for a maximum of 6 h. Discard any vial left at room temperature for >6 h. PREPARE: Intermittent/Continuous: May dilute with 10-50 mL D5W to yield 15 mcg/mL or greater. If more diluent is used to yield concentrations of 5-15 mcg/mL, 2 mL of 5% human albumin must be added for each 50 mL D5W (prior to adding filgrastim) to prevent adsorption to plastic IV infusion materials. ADMINISTER: Intermittent: Give a single dose over 15-30 min. Continuous: Give a single dose over 4-24 h. INCOMPATIBILITIES Y-site: Amphotericin B, cefepime, cefoperazone, cefotaxime, cefoxitin, ceftizoxime, ceftriaxone, cefuroxime, clindamycin, dactinomycin, etoposide, fluorouracil, furosemide, gentamicin, heparin, imipenem, mannitol, methylprednisolone, metronidazole, mitomycin, piperacillin, prochlorperazine, thiotepa. Store refrigerated at 2°-8° C (36°-46° F). Do not freeze. Avoid shaking. Adverse Effects (1%) CV: Abnormal ST segment depression. Hematologic: Anemia. GI: Nausea, anorexia. Body as a Whole: Bone pain, hyperuricemia, fever. Diagnostic Test Interference Elevations in leukocyte alkaline phosphatase, serum alkaline phosphatase, lactate dehydrogenase, and uric acid have been reported. These elevations appear to be related to increased bone marrow activity. Interactions Drug: Can interfere with activity of CYTOTOXIC AGENTS, do not use 24 h before or after CYTOTOXIC AGENTS Pharmacokinetics Absorption: Readily absorbed from SC site. Onset: 4 h. Peak: 1 h. Elimination: Probably excreted in urine. Half-Life: 1.4-7.2 h. Nursing Implications Assessment & Drug Effects Lab tests: Obtain a baseline CBC with differential and platelet count prior to administering drug. Obtain CBC twice weekly during therapy to monitor neutrophil count and leukocytosis. Monitor Hct and platelet count regularly. Discontinue filgrastim if absolute neutrophil count exceeds 10,000/mm3 after the chemotherapy-induced nadir. Neutrophil counts should then return to normal. Monitor patients with preexisting cardiac conditions closely. MI and arrhythmias have been associated with a small percent of patients receiving filgrastim. Monitor temperature q4h. Incidence of infection should be reduced after administration of filgrastim. Assess degree of bone pain if present. Consult physician if nonnarcotic analgesics do not provide relief. Patient & Family Education Report bone pain and, if necessary, to request analgesics to control pain. Note: Proper drug administration and disposal is important. A puncture-resistant container for the disposal of used syringes and needles should be available to the patient. Do not breast feed while taking this drug without consulting physician.

Esomeprazole

Nexium Classifications: GASTROINTESTINAL AGENT; PROTON PUMP INHIBITOR Prototype: Omeprazole Pregnancy Category: B Availability 20 mg, 40 mg capsules; 20 mg, 40 mg powder for injection Actions Isomer of omeprazole. A weak base that is converted to the active form in the highly acidic environment of the secretory surface of the gastric parietal cells. Inhibits the enzyme H+K+-ATPase (the acid pump). Therapeutic Effects Due to inhibition of the H+K+-ATPase, esomeprazole substantially decreases both basal and stimulated acid secretion through inhibition of the acid pump in parietal cells. Uses Erosive esophagitis, gastrointestinal reflux disease (GERD), duodenal ulcer associated with H. pylori in combination with antibiotics. Contraindications Hypersensitivity to esomeprazole magnesium, omeprazole, or other proton pump inhibitors; gastric malignancy; lactation. Cautious Use Severe renal insufficiency; sever hepatic impairment; treatment for more than a year; gastric ulcers; pregnancy (category C). Safety and efficacy in children are not established. Route & Dosage Healing of Erosive Esophagitis Adult: PO or IV 20-40 mg q.d. at least 1 h before meals times 4-8 wks GERD, Erosive Esophagitis Maintenance Adult: PO 20 mg q.d. Duodenal Ulcer Adult: PO 40 mg q.d. times 10 d Administration Oral Give at least 1 h before eating. Do not crush or chew capsule. Must be swallowed whole. Open capsule and mix pellets with applesauce (cold or room temperature) if patient cannot swallow capsules. Do NOT crush pellets. Applesauce should be swallowed immediately after mixing without chewing. May take with antacids. Store in the original blister package 15°-30° C (59°-86° F). Intravenous PREPARE: Direct: Reconstitute powder with 5 mL of NS. IV Infusion: Further dilute reconstituted solution in 50 mL of NS, LR, or D5W. ADMINISTER: Direct: Withdraw 5 mL of reconstituted solution and give over no less than 3 min. IV Infusion: Give IV solution over 10-30 min. INCOMPATIBILITIES Do not give simultaneously with any other medication through the same IV site or line. Flush IV line with NS, LR, or D5W before/after infusion. Store reconstituted solution at room temperature up to 30° C (86° F); give within 12 h of reconstitution with NS or LR and within 6 h of reconstitution with D5W. Adverse Effects (1%) CNS: Headache. GI: Nausea, vomiting, diarrhea, constipation, abdominal pain, flatulence, dry mouth. Interactions Drug: May increase diazepam, phenytoin, warfarin levels. Food: Food decreases absorption by up to 35%. Pharmacokinetics Absorption: Destroyed in acidic environment, therefore capsules are designed for delayed absorption in the small intestine. 70% reaches systemic circulation. Metabolism: Metabolized in liver by CYP2C19. Elimination: Inactive metabolites excreted in both urine and feces. Half-Life: 1.5 h. Nursing Implications Assessment & Drug Effects Monitor for S&S of adverse CNS effects (vertigo, agitation, depression) especially in severely ill patients. Monitor phenytoin levels with concurrent use. Monitor INR/PT with concurrent warfarin use. Lab tests: Periodic liver function tests, CBC, Hct & Hbg, urinalysis for hematuria and proteinuria. Patient & Family Education Report any changes in urinary elimination such as pain or discomfort associated with urination to physician. Report severe diarrhea. Drug may need to be discontinued. Do not breast feed while taking this drug without consulting physician.

Promethazine

Pentazine, Phencen, Phenergan, Phenoject-50, Prometh, Prorex, Prothazine, V-Gan Classifications: GASTROINTESTINAL AGENT; ANTIEMETIC; ANTIVERTIGO AGENT; PHENOTHIAZINE Prototype: Prochlorperazine Pregnancy Category: C Availability 12.5 mg, 25 mg, 50 mg tablets; 6.25 mg/5 mL syrup; 12.5 mg, 25 mg, 50 mg suppositories; 25 mg/mL, 50 mg/mL injection Actions Long-acting derivative of phenothiazine with marked antihistamine activity and prominent sedative, amnesic, antiemetic, and anti-motion-sickness actions. Unlike other phenothiazine derivatives, relatively free of extrapyramidal adverse effects; however, in high doses it carries same potential for toxicity. Therapeutic Effects In common with other antihistamines, exerts antiserotonin, anticholinergic, and local anesthetic action. Antiemetic action thought to be due to depression of CTZ in medulla. Uses Symptomatic relief of various allergic conditions, to ameliorate and prevent reactions to blood and plasma, and in prophylaxis and treatment of motion sickness, nausea, and vomiting. Preoperative, postoperative, and obstetric sedation and as adjunct to analgesics for control of pain. Contraindications Hypersensitivity to phenothiazines; narrow-angle glaucoma; stenosing peptic ulcer, pyloroduodenal obstruction; prostatic hypertrophy; bladder neck obstruction; epilepsy; bone marrow depression; comatose or severely depressed states; pregnancy (category C), lactation, newborn or premature infants, acutely ill or dehydrated children; children <2 y; Reye's syndrome, encephalopathy, hepatic diseases. Cautious Use Impaired liver function; cardiovascular disease; asthma; acute or chronic respiratory impairment (particularly in children); hypertension; older adult or debilitated patients; children >2 y. Route & Dosage Motion Sickness Adult: PO/PR/IM/IV 25 mg b.i.d. Child: PO/PR/IM/IV 12.5-25 mg b.i.d. Nausea Adult: PO/PR/IM/IV 12.5-25 mg q4-6h prn Child: PO/PR/IM/IV 0.25-0.5 mg/kg q4-6h prn Allergies Adult: PO/PR/IM/IV 12.5 mg q.i.d. or 25 mg h.s. Child: PO/PR/IM/IV 6.25-12.5 mg q.i.d. or 25 mg h.s. Sedation Adult: PO/PR/IM/IV 25-50 mg preoperatively or h.s. Child: PO/PR/IM/IV 12.5-25 mg preoperatively or h.s. Administration Oral Give with food, milk, or a full glass of water may minimize GI distress. Tablets may be crushed and mixed with water or food before swallowing. Oral doses for allergy are generally prescribed before meals and on retiring or as single dose at bedtime. Intramuscular Give IM injection deep into large muscle mass. Aspirate carefully before injecting drug. Intraarterial injection can cause arterial or arteriolar spasm, with resultant gangrene. Subcutaneous injection (also contraindicated) can cause chemical irritation and necrosis. Rotate injection sites and observe daily. Intravenous PREPARE: Direct: • Concentrations of 25 mg/mL or less may be given undiluted. Dilute more concentrated preparations in NS to yield no more than 25 mg/mL (e.g., diluting the 50 mg/mL concentration in 9 mL yields 5 mg/mL).• Inspect parenteral drug before preparation. Discard if it is darkened or contains precipitate. ADMINISTER: Direct: Give each 25 mg over at least 1 min. INCOMPATIBILITIES Solution/additive: Aminophylline, carbenicillin, cefotetan, chloramphenicol, chlorothiazide, heparin, hydrocortisone, methicillin, methohexital, penicillin G sodium, pentobarbital, phenobarbital, thiopental, diatrizoate, dimenhydrinate, iodipamide, iothalamate, nalbuphine. Y-site: Aldesleukin, allopurinol, amphotericin B cholesteryl complex, cefepime, cefoperazone, cefotetan, doxorubicin liposome, foscarnet, heparin, methotrexate. Store at 15°-30° C (59°-86° F) in tight, light-resistant container unless otherwise directed. Adverse Effects (1%) Body as a Whole: Deep sleep, coma, convulsions, cardiorespiratory symptoms, extrapyramidal reactions, nightmares (in children), CNS stimulation, abnormal movements. Respiratory: Irregular respirations, respiratory depression, apnea. CNS: Sedation drowsiness, confusion, dizziness, disturbed coordination, restlessness, tremors. CV: Transient mild hypotension or hypertension. GI: Anorexia, nausea, vomiting, constipation. Hematologic: Leukopenia, agranulocytosis. Special Senses: Blurred vision, dry mouth, nose, or throat. Skin: Photosensitivity. Urogenital: Urinary retention. Diagnostic Test Interference Promethazine may interfere with blood grouping in ABO system and may produce false results with urinary pregnancy tests (Gravindex, false-positive; Prepurex and Dap tests, false-negative). Promethazine can cause significant alterations of flare response in intradermal allergen tests if performed within 4 d of patient's receiving promethazine. Interactions Drug: Alcohol and other CNS DEPRESSANTS add to CNS depression and anticholinergic effects. Pharmacokinetics Absorption: Readily absorbed from GI tract. Onset: 20 min PO/PR/IM; 5 min IV. Duration: 2-8 h. Distribution: Crosses placenta. Metabolism: Metabolized in liver. Elimination: Slowly excreted in urine and feces. Nursing Implications Assessment & Drug Effects Supervise ambulation. Promethazine sometimes produces marked sedation and dizziness. Be aware that antiemetic action may mask symptoms of unrecognized disease and signs of drug overdosage as well as dizziness, vertigo, or tinnitus associated with toxic doses of aspirin or other ototoxic drugs. Patients in pain may develop involuntary (athetoid) movements of upper extremities following parenteral administration. These symptoms usually disappear after pain is controlled. Monitor respiratory function in patients with respiratory problems, particularly children. Drug may suppress cough reflex and cause thickening of bronchial secretions. Patient & Family Education For motion sickness: Take initial dose 30-60 min before anticipated travel and repeat at 8-12 h intervals if necessary. For duration of journey, repeat dose on arising and again at evening meal. Do not drive or engage in other potentially hazardous activities requiring mental alertness and normal reaction time until response to drug is known. Avoid sunlamps or prolonged exposure to sunlight. Use sunscreen lotion during initial drug therapy. Do not take OTC medications without physician's approval. Avoid alcohol and other CNS depressants. Relieve dry mouth by frequent rinses with water or by increasing noncaloric fluid intake (if allowed), chewing sugarless gum, or sucking hard candy. If these measures fail, add a saliva substitute (e.g., Moi-Stir, Orex, Xero-Lube). Do not breast feed while taking this drug.

Testosterone

Androderm, AndroGel, Striant, Testoderm, Testoderm TTS, Testopel, Testim TESTOSTERONE CYPIONATE Andro-Cyp, Depo-Testosterone, Depotest TESTOSTERONE ENANTHATE Delatest, Delatestryl, Malogex Classifications: HORMONES AND SYNTHETIC SUBSTITUTES; ANDROGEN/ANABOLIC STEROID; ANTINEOPLASTIC Pregnancy Category: X Controlled Substance: Schedule III Availability Testosterone 75 mg implantable pellets; 2.5 mg/24 h, 4 mg/24 h, 5 mg/24 h, 6 mg/24 h, transdermal patch; 1% gel; 2.5 g, 5 g gel packets; 30 mg buccal patch Testosterone Cypionate 100 mg/mL, 200 mg/mL injection Testosterone Enanthate 100 mg/mL, 200 mg/mL injection Actions Synthetic steroid compound with both androgenic and anabolic activity (1:1). Controls development and maintenance of secondary sexual characteristics. Androgenic activity: Responsible for the growth spurt of the adolescent and for growth termination by epiphyseal closure. In males and some females, reduces excretion of phosphorus, nitrogen, potassium, sodium, and chloride. Increases erythropoiesis, possibly by stimulating production of renal or extrarenal erythropoietin, and promotes vascularization and darkening of skin. Anabolic activity: Increases protein metabolism and decreases its catabolism. Large doses suppress spermatogenesis, thereby causing testicular atrophy. Therapeutic Effects Antagonizes effects of estrogen excess on female breast and endometrium. Responsible for the growth spurt of the adolescent male and onset of puberty. Uses Androgen replacement therapy, delayed puberty (male), palliation of female mammary cancer (1-5 y postmenopausal), and to treat postpartum breast engorgement. Available in fixed combination with estrogens in many preparations. Contraindications Hypersensitivity or toxic reactions to androgens; serious cardiac, liver, or kidney disease; hypercalcemia; known or suspected prostatic or breast cancer in male; benign prostatic hypertrophy with obstruction; patients easily stimulated sexually; older adults; asthenic males who may react adversely to androgenic overstimulation; conditions aggravated by fluid retention; hypertension. Pregnancy (category X), possibility of virilization of external genitalia of female fetus, lactation. Cautious Use Cardiac, liver, and kidney disease; prepubertal males, geriatric patients, acute intermittent porphyria. Route & Dosage Male Hypogonadism Adult: IM Cypionate, Enanthate 50-400 mg q2-4wk Topical Start with 6 mg/d system applied daily, if scrotal area inadequate, use 4 mg/d system; Androderm Apply to torso; AndroGel Apply one packet to upper arms, shoulders, or abdomen once daily; Striant Apply one patch to the gum region just above the incisor tooth q12h Delayed Puberty Adult: IM Cypionate, Enanthate 50-200 mg q2-4wk Metastatic Breast Cancer Adult: IM Cypionate, Enanthate 200-400 mg q2-4wk Administration Buccal Apply buccal patch to gum just above the incisor tooth. Transdermal Apply transdermal system on clean, dry scrotal skin. Dry shave scrotal hair for optimal skin contact. Do not use chemical depilatories. Wear patch for 22-24 h. Apply Androderm patches to abdomen, back, thigh, or upper arm. Alternate application site q24h with 7 d between same site. Store at 15°-30° C (59°-86° F). Intramuscular Give IM injections deep into gluteal musculature. Store IM formulations prepared in oil at room temperature. Warming and shaking vial will redisperse precipitated crystals. Adverse Effects (1%) CNS: Excitation, insomnia. CV: Skin flushing and vascularization. GI: Nausea, vomiting, anorexia, diarrhea, gastric pain, jaundice. Hematologic: Leukopenia. Metabolic: Hypercalcemia, hypercholesterolemia, sodium and water retention (especially in older adults) with edema. Renal: Renal calculi (especially in the immobilized patient), bladder irritability. Urogenital: Increased libido. Skin: Acne, injection site irritation and sloughing. Body as a Whole: Hypersensitivity to testosterone, anaphylactoid reactions (rare). Hematologic: Precipitation of acute intermittent porphyria. Endocrine: Female—suppression of ovulation, lactation, or menstruation; hoarseness or deepening of voice (often irreversible); hirsutism; oily skin; clitoral enlargement; regression of breasts; male-pattern baldness (in disseminated breast cancer); flushing, sweating; vaginitis with pruritus, drying, bleeding; menstrual irregularities. Male—prepubertal-premature epiphyseal closure, phallic enlargement, priapism. Postpubertal—testicular atrophy, decreased ejaculatory volume, azoospermia, oligospermia (after prolonged administration or excessive dosage), impotence, epididymitis, priapism, gynecomastia. Diagnostic Test Interference Testosterone alters glucose tolerance tests; decreases thyroxine-binding globulin concentration (resulting in decreased total T4 serum levels and increased resin of T3 and T4 ). Increases creatinine and creatinine excretion (lasting up to 2 wk after therapy is discontinued) and alters response to metyrapone test. It suppresses clotting factors II, V, VII, X and decreases excretion of 17-ketosteroids. May increase or decrease serum cholesterol. Interactions Drug: ORAL ANTICOAGULANTS may potentiate hypoprothrombinemia. May decrease insulin requirements. Pharmacokinetics Absorption: Cypionate and enanthate are slowly absorbed from lipid tissue. Duration: 2-4 wk cypionate and enanthate. Distribution: 98% bound to sex hormone-binding globulin. Metabolism: Primarily metabolized in liver. Elimination: 90% excreted in urine, 6% in feces. Half-Life: 10-100 min. Nursing Implications Assessment & Drug Effects Therapeutic response from testosterone therapy is slow; breast cancer, usually apparent within 3 mo after regimen begins. Terminate therapy if signs of disease progression appear. Check I&O and weigh patient daily during dose adjustment period. Weight gain (due to sodium and water retention) suggests need for decreased dosage. When dosage is stabilized, urge patient to check weight at least twice weekly and to report increases, particularly if accompanied by edema in dependent areas. Dose adjustment and diuretic therapy may be started. Lab tests: Periodic serum cholesterol, serum electrolytes as well as liver function tests throughout therapy. Monitor serum calcium closely. Androgenic therapy is usually terminated if serum calcium rises above 14 mg/dL. Report S&S of hypercalcemia (see Appendix F) promptly. The immobilized patient is particularly prone to develop hypercalcemia, which indicates progression of bone metastasis in patients with metastatic breast cancer. Treatment includes withdrawing testosterone and checking calcium, phosphate, and BUN levels daily. Instruct diabetic to report sweating, tremor, anxiety, vertigo. Testosterone-induced anabolic action enhances hypoglycemia (hyperinsulinism). Dosage adjustment of antidiabetic agent may be required. Observe patients on concomitant anticoagulant treatment for signs of overdosage (e.g., ecchymoses, petechiae). Report promptly to physician; anticoagulant dose may need to be reduced. Monitor prepubertal or adolescent males throughout therapy to avoid precocious sexual development and premature epiphyseal closure. Skeletal stimulation may continue 6 mo beyond termination of therapy. Patient & Family Education Review directions for application of transdermal patches. Report soreness at injection site, because postinjection furunculosis may be an associated adverse reaction. Report priapism (sustained and often painful erections occurring especially in early replacement therapy), reduced ejaculatory volume, and gynecomastia to physician. Symptoms indicate necessity for temporary withdrawal or discontinuation of testosterone therapy. Notify physician promptly if pregnancy is suspected or planned. Masculinization of the fetus is most likely to occur if testosterone (androgen) therapy is provided during first trimester of pregnancy. Androgens may cause virilism in women at dosage required to treat carcinoma. Report increase in libido (early sign of toxicity), growth of facial hair, deepening of voice, male-pattern baldness. The onset of hoarseness can easily be overlooked unless its significance as an early and possibly irreversible sign of virilism is appreciated. Reevaluation of treatment plan is indicated.

Lidocaine

Anestacon, Dilocaine, L-Caine, Lidoderm, Lida-Mantle, Lidoject-1, LidoPen Auto Injector, Nervocaine, Octocaine, Xylocaine, Xylocard Classifications: CARDIOVASCULAR AGENT; ANTIARRHYTHMIC, CLASS IB; CENTRAL NERVOUS SYSTEM AGENT; LOCAL ANESTHETIC (AMIDE TYPE) Pregnancy Category: B Availability Antidysrhythmic 300 mg/3 mL auto-injector; 0.2%, 0.4%, 0.8%, 1%, 2%, 4%, 10%, 20% injections Local Anesthetic 0.5%, 1%, 1.5%, 2%, 4% Topical 2%, 2.5%, 4%, 5% solution; 2.5%, 5% ointment; 0.5%, 4% cream; 0.5%, 2.5% gel; 0.5%, 10% spray; 2% jelly; 0.5% patch Actions Similar to those of procainamide and quinidine, but has little effect on myocardial contractility, AV and intraventricular conduction, cardiac output, and systolic arterial pressure in equivalent doses. Exerts antiarrhythmic action (Class IB) by suppressing automaticity in His-Purkinje system and by elevating electrical stimulation threshold of ventricle during diastole. Action as local anesthetic is more prompt, more intense, and longer lasting than that of procaine. Therapeutic Effects Suppresses automaticity in His-Purkinje system and elevates electrical stimulation threshold of ventricle during diastole. Prompt, intense, and long-lasting local anesthetic. Uses Rapid control of ventricular arrhythmias occurring during acute MI, cardiac surgery, and cardiac catheterization and those caused by digitalis intoxication. Also as surface and infiltration anesthesia and for nerve block, including caudal and spinal block anesthesia and to relieve local discomfort of skin and mucous membranes. Patch for relief of pain associated with post-herpetic neuralgia. Unlabeled Uses Refractory status epilepticus. Contraindications History of hypersensitivity to amide-type local anesthetics; application or injection of lidocaine anesthetic in presence of severe trauma or sepsis, blood dyscrasias, supraventricular arrhythmias, Stokes-Adams syndrome, untreated sinus bradycardia, severe degrees of sinoatrial, atrioventricular, and intraventricular heart block. Safe use during pregnancy (category B), lactation, or in children is not established. Cautious Use Liver or kidney disease, CHF, marked hypoxia, respiratory depression, hypovolemia, shock; myasthenia gravis; debilitated patients, older adults; family history of malignant hyperthermia (fulminant hypermetabolism). Topical use in eyes, over large body areas, over prolonged periods, in severe or extensive trauma or skin disorders. Route & Dosage Ventricular Arrhythmias Adult: IV 50-100 mg bolus at a rate of 20-50 mg/min, may repeat in 5 min, then start infusion of 1-4 mg/min immediately after first bolus IM/SC 200-300 mg IM, may repeat once after 60-90 min Child: IV 0.5-1 mg/kg bolus dose, then 10-50 mcg/kg/min infusion Anesthetic Uses Adult: Infiltration 0.5-1% solution Nerve Block 1-2% solution Epidural 1-2% solution Caudal 1-1.5% solution Spinal 5% with glucose Saddle Block 1.5% with dextrose Topical 2.5-5% jelly, ointment, cream, or solution Post-Herpetic Neuralgia Adult: Topical Apply up to 3 patches over intact skin in most painful areas once for up to 12 h per 24 h period Administration Intramuscular Give in deltoid muscle as preferred site. Topical Do not apply topical lidocaine to large areas of skin or to broken or abraded surfaces. Consult physician about covering area with a dressing. Avoid topical preparation contact with eyes. Intravenous Note: Do not use lidocaine solutions containing preservatives for spinal or epidural (including caudal) block. Use ONLY lidocaine HCl injection without preservatives or epinephrine that is specifically labeled for IV injection or infusion. PREPARE: Direct: Give undiluted. IV Infusion: • Use D5W for infusion. For adults, add 1 g to 250 or 500 mL to yield 2 or 4 mg/mL, respectively; for children, add 120 mg to 100 m to yield 1.2 mg/mL.• Do not use solutions with particulate matter or discoloration. ADMINISTER: Direct: Give at a rate of 50 mg or fraction thereof over 1 min. IV Infusion: Use microdrip and infusion pump. Rate of flow is usually 4 mg/min. INCOMPATIBILITIES Solution/additive: Phenytoin, ampicillin, cefazolin. Y-site: Amphotericin B cholesteryl complex, phenytoin, thiopental. Discard partially used solutions of lidocaine without preservatives. Adverse Effects (1%) CNS: Drowsiness, dizziness, light-headedness, restlessness, confusion, disorientation, irritability, apprehension, euphoria, wild excitement, numbness of lips or tongue and other paresthesias including sensations of heat and cold, chest heaviness, difficulty in speaking, difficulty in breathing or swallowing, muscular twitching, tremors, psychosis. With high doses: convulsions, respiratory depression and arrest. CV: With high doses, hypotension, bradycardia, conduction disorders including heart block, cardiovascular collapse, cardiac arrest. Special Senses: Tinnitus, decreased hearing; blurred or double vision, impaired color perception. Skin: Site of topical application may develop erythema, edema. GI: Anorexia, nausea, vomiting. Body as a Whole: Excessive perspiration, soreness at IM site, local thrombophlebitis (with prolonged IV infusion), hypersensitivity reactions (urticaria, rash, edema, anaphylactoid reactions). Diagnostic Test Interference Increases in creatine phosphokinase (CPK) level may occur for 48 h after IM dose and may interfere with test for presence of MI. Interactions Drug: Lidocaine patch may increase toxic effects of tocainide, mexiletine; BARBITURATES decrease lidocaine activity; cimetidine, BETA BLOCKERS, quinidine increase pharmacologic effects of lidocaine; phenytoin increases cardiac depressant effects; procainamide compounds neurologic and cardiac effects. Pharmacokinetics Absorption: Topical application is 3% absorbed through intact skin. Onset: 45-90 sec IV; 5-15 min IM; 2-5 min topical. Duration: 10-20 min IV; 60-90 min IM; 30-60 min topical; >100 min injected for anesthesia. Distribution: Crosses blood-brain barrier and placenta; distributed into breast milk. Metabolism: Metabolized in liver. Elimination: Excreted in urine. Half-Life: 1.5-2 h. Nursing Implications Assessment & Drug Effects Stop infusion immediately if ECG indicates excessive cardiac depression (e.g., prolongation of PR interval or QRS complex and the appearance or aggravation of arrhythmias). Monitor BP and ECG constantly; assess respiratory and neurologic status frequently to avoid potential overdosage and toxicity. Auscultate lungs for basilar rales, especially in patients who tend to metabolize the drug slowly (e.g., CHF, cardiogenic shock, hepatic dysfunction). Watch for neurotoxic effects (e.g., drowsiness, dizziness, confusion, paresthesias, visual disturbances, excitement, behavioral changes) in patients receiving IV infusions or with high lidocaine blood levels. Note: Lidocaine blood levels of 1.5-6 mcg/mL are reported to provide "usually effective" antiarrhythmic activity. Blood levels greater than 7 mcg/mL are potentially toxic. Patient & Family Education Swish and spit out when using lidocaine solution for relief of mouth discomfort; gargle for use in pharynx, may be swallowed (as prescribed). Oral topical anesthetics (e.g., Xylocaine Viscous) may interfere with swallowing reflex. Do NOT ingest food within 60 min after drug application; especially pediatric, geriatric, or debilitated patients. Do not chew gum while buccal and throat membranes are anesthetized to prevent biting trauma. Do not breast feed while taking this drug without consulting physician

Epidural

BUPIVACAINE HYDROCHLORIDE (byoo-piv'a-kane) Marcaine, Sensorcaine Classifications: CENTRAL NERVOUS SYSTEM AGENT; LOCAL ANESTHETIC (AMIDE-TYPE) Prototype: Procaine Pregnancy Category: C Availability 0.25%, 0.5%, 0.75% injection Actions Anesthetic of the amide type. Decreases sodium flux into nerve cell, inhibiting initial depolarization, and prevents propagation and conduction of the nerve impulse. Progression of anesthesia, related to diameter, myelination, and conduction velocity of affected fibers is manifested clinically as sequential loss of nerve function. May stimulate or depress the CNS or do both. Therapeutic Effects Primary depressant effect is in medulla and higher centers affecting patient's reaction to pain, temperature, and touch, as well as proprioception and skeletal muscle tone. Uses Infiltration anesthesia; peripheral, sympathetic nerve, and epidural (including caudal) block anesthesia; 0.75% bupivacaine solution in dextrose is used for spinal anesthesia. Contraindications Known sensitivity to bupivacaine, local anesthetics, other amide-type anesthetics. Parabens, or metabisulfites; acidosis; heart block; severe hemorrhage; hypotension and shock; hypertension, cerebrospinal diseases; obstetrical paracervical anesthesia or spinal anesthesia in septicemia; topical or IV regional anesthesia; intercurrent use with chloroprocaine; history of malignant hyperthermia. Safety during pregnancy (category C) other than during labor, lactation, or children <12 y is not established. Cautious Use Older adults or debilitated patients; hepatic or renal disease; known drug allergies and sensitivities; dysrhythmias; children >12 y; obstetrical delivery. Route & Dosage Infiltration Anesthesia Adult: IM Local infiltration, sympathetic block 0.25% solution; Lumbar epidural 0.25%, 0.5%, 0.75% solutions; Caudal block, peripheral nerve block 0.25%, 0.5% solutions; Retrobulbar block 0.75% solution Child: IM 1-3.7 mg/kg Administration Intramuscular Inject slowly with frequent aspirations to avoid intravascular injection. Intrathecal Do not use preparations containing preservatives for epidural or spinal anesthesia. Do not use multiple-dose vial for lumbar or caudal epidural block. Store ampuls at 15°-30° C (59°-86° F); protect from freezing. Solutions with epinephrine should be protected from light. INCOMPATIBILITIES Solution/additive: Sodium bicarbonate Adverse Effects (1%) Body as a Whole: Hypersensitivity [cutaneous lesions, urticaria, sneezing, diaphoresis, syncope, hyperthermia, angioneurotic edema (including laryngeal edema), anaphylaxis, anaphylactoid reaction]. CNS: Nervousness, unusual anxiety, excitement, dizziness, drowsiness, tremors, convulsions, unconsciousness, respiratory arrest. Special Senses: Pupillary constriction; blurred or double vision; tinnitus. GI: Nausea, vomiting. Other: Inflammation or sepsis at injection site, chills, pupillary constriction. Associated with Epidural Anesthesia, Body as a Whole: Total spinal block, persistent analgesia, paresthesia. Urogenital: Urinary retention, fecal incontinence, loss of perineal sensation and sexual function. Other: Slowing of labor, increased incidence of forceps delivery, cranial nerve palsies (with inadvertent intrathecal injection). Interactions Drug: CNS DEPRESSANTS augment CNS depression; with isoproterenol, ergonovine there is persistent hypertension and a risk of CVA if bupivacaine used with epinephrine. MAO INHIBITORS, TRICYCLIC ANTIDEPRESSANTS, PHENOTHIAZINES cause severe or prolonged hypotension or hypertension if bupivacaine used with epinephrine. Pharmacokinetics Onset: 4-17 min for epidural, caudal, peripheral, or sympathetic block; within 1 min for spinal block. Duration: 3-5 h for epidural, caudal, peripheral, or sympathetic block; 1.25-2.5 h for spinal block. Distribution: Crosses placenta. Metabolism: Metabolized in liver. Elimination: 6% excreted unchanged in urine. Half-Life: 1.5-5.5 h in adults, 8.1 h in neonates. Nursing Implications Assessment & Drug Effects Monitor for signs of inadvertent intravascular injection, which can produce a transient "epinephrine response" (increased heart rate or systolic BP or both, circumoral pallor, palpitations, nervousness) within 45 seconds in the unsedated patient and an increase by 20 bpm or more in heart rate for at least 15 seconds in sedated patient. Vasoconstrictor-containing solution should be administered cautiously, if at all, to areas with end arteries (e.g., digits, penis) or to areas that have a compromised blood supply; ischemia and gangrene can result. Inspect areas for evidence of reduced perfusion because of vasospasm: pale, cold, sensitive skin. Note: Systemic reactions (toxicity) are more apt to occur in children or older adults and may develop rapidly or be delayed for as long as 30 min after administration. Monitor for toxicity: CNS stimulation (unusual anxiety, excitement, restlessness) usually occurs first, followed by CNS depression (drowsiness, unconsciousness, respiratory arrest). However, because stimulation is apt to be transient or absent, drowsiness may be the first sign in some patients (especially children and older adults). Monitor BP and fetal heart rate continuously during labor because maternal hypotension may accompany regional anesthesia. Place mother on left side with legs elevated. Monitor cardiac and respiratory status continuously in patients receiving retrobulbar and dental blocks. Patient & Family Education After spinal anesthesia, sensation to lower extremities may not return for 2.5-3.5 h.

Phenelzine

Nardil Classifications: CENTRAL NERVOUS SYSTEM AGENT; PSYCHOTHERAPEUTIC; ANTIDEPRESSANT; MONOAMINE OXIDASE (MAO) INHIBITOR Pregnancy Category: C Availability 15 mg tablets Actions Potent hydrazine (monoamine oxidase) MAO inhibitor. Precise mode of action is not known. Antidepressant and diverse effects believed to be due to irreversible inhibition of MAO, thereby permitting increased concentrations of endogenous epinephrine, norepinephrine, serotonin, and dopamine within presynaptic neurons and at receptor sites. Also thought to inhibit hepatic microsomal drug-metabolizing enzymes; thus it may intensify and prolong the effects of many drugs. Therapeutic Effects Antidepressant utilization of the drug is limited to individuals who do not respond well to other classes of antidepressants. Termination of drug action depends on regeneration of MAO, which occurs 2-3 wk after discontinuation of therapy. Uses Management of endogenous depression, depressive phase of manic-depressive psychosis, and severe exogenous (reactive) depression not responsive to more commonly used therapy. Contraindications Hypersensitivity to MAO inhibitors; pheochromocytoma; hyperthyroidism; CHF, cardiovascular or cerebrovascular disease; impaired kidney function, hypernatremia; atonic colitis; glaucoma; history of frequent or severe headaches; history of liver disease, abnormal liver function tests; older adult or debilitated patients; paranoid schizophrenia. Safety during pregnancy (category C), lactation, or in children <6 y of age is not established. Cautious Use Epilepsy; pyloric stenosis; diabetes; depression accompanying alcoholism or drug addiction; manic-depressive states; agitated patients; suicidal tendencies; chronic brain syndromes; history of angina pectoris. Route & Dosage Depression Adult: PO 15 mg t.i.d., rapidly increase to at least 60 mg/d, may need up to 90 mg/d Administration Oral Discontinue at least 10 d before elective surgery to allow time for recovery from MAO before anesthetics are given. Avoid rapid withdrawal of MAO inhibitors, particularly after high dosage, since a rebound effect may occur (e.g., headache, excitability, hallucinations, and possibly depression). Store in tightly covered containers away from heat and light. Adverse Effects (1%) Body as a Whole: Dizziness or vertigo, headache, orthostatic hypotension, drowsiness or insomnia, weakness, fatigue, edema, tremors, twitching, akathisia, ataxia, hyperreflexia, faintness, hyperactivity, marked agitation, anxiety, seizures, trismus, opisthotonos, respiratory depression, coma. CNS: Mania, hypomania, confusion, memory impairment, delirium, hallucinations, euphoria, acute anxiety reaction, toxic precipitation of schizophrenia, convulsions, peripheral neuropathy. CV: Hypertensive crisis (intense occipital headache, palpitation, marked hypertension, stiff neck, nausea, vomiting, sweating, fever, photophobia, dilated pupils, bradycardia or tachycardia, constricting chest pain, intracranial bleeding), hypotension or hypertension, circulatory collapse. GI: Constipation, dry mouth, nausea, vomiting, anorexia, weight gain. Hematologic: Normocytic and normochromic anemia, leukopenia. Skin: Hyperhidrosis, skin rash, photosensitivity. Special Senses: Blurred vision. Diagnostic Test Interference Phenelzine may cause a slight false increase in serum bilirubin. Interactions Drug: TRICYCLIC ANTIDEPRESSANTS may cause hyperpyrexia, seizures; fluoxetine, sertraline, paroxetine may cause hyperthermia, diaphoresis, tremors, seizures, delirium; SYMPATHOMIMETIC AGENTS (e.g., amphetamine, phenylephrine, phenylpropanolamine), guanethidine and reserpine may cause hypertensive crisis; CNS DEPRESSANTS have additive CNS depressive effects; OPIATE ANALGESICS (especially meperidine) may cause hypertensive crisis and circulatory collapse; buspirone, hypertension; GENERAL ANESTHETICS, prolonged hypotensive and CNS depressant effects; hypertension, headache, hyperexcitability reported with dopamine, methyldopa, levodopa, tryptophan; metrizamide may increase risk of seizures; HYPOTENSIVE AGENTS and DIURETICS have additive hypotensive effects. Food: Aged meats or aged cheeses, protein extracts, sour cream, alcohol, anchovies, liver, sausages, overripe figs, bananas, avocados, chocolate, soy sauce, bean curd, natural yogurt, fava beans—tyramine-containing foods—may precipitate hypertensive crisis. Avoid chocolate or caffeine. Herbal: Ginseng, ephedra, ma huang, St. John's wort may cause hypertensive crisis. Pharmacokinetics Absorption: Readily absorbed from GI tract. Onset: 2 wk. Metabolism: Rapidly metabolized. Elimination: 79% of metabolites excreted in urine in 96 h. Nursing Implications Assessment & Drug Effects Evaluate patient's BP in standing and recumbent positions. Prior to initiation of treatment. Lab tests: Perform baseline CBC and liver function tests. Also perform periodic CBC and liver function tests during prolonged or high-dose therapy. Monitor BP and pulse between doses when titrating initial dosages. Observe closely for evidence of adverse drug effects. Thereafter, monitor at regular intervals throughout therapy. Report immediately if hypomania (exaggeration of motility, feelings, and ideas) occurs as depression improves. This reaction may also appear at higher than recommended doses or with long-term therapy. Observe for and report therapeutic effectiveness of drug: Improvement in sleep pattern, appetite, physical activity, interest in self and surroundings, as well as lessening of anxiety and bodily complaints. Observe patient with diabetes closely for S&S of hypoglycemia (see Appendix F). Patients on prolonged therapy should be checked periodically for altered color perception, changes in fundi or visual fields. Changes in red-green vision may be the first indication of eye damage. Patient & Family Education Drug is usually discontinued if no therapeutic response occurs after 3 or 4 wk. Maximum antidepressant effects generally appear in 2-6 wk and persist several weeks after drug withdrawal. Avoid self-medication. OTC preparations containing dextromethorphan, sympathomimetic agents, or antihistamines (e.g., cough, cold, and hay fever remedies, appetite suppressants) can precipitate severe hypertensive reactions if taken during therapy or within 2-3 wk after discontinuation of an MAO inhibitor. Report immediately to physician the onset of headache and palpitation, prodromal symptoms of hypertensive crisis or any other unusual effects which may indicate need to discontinue therapy. Do not consume foods and beverages containing tyramine or tryptophan or drugs containing pressor agent. These can cause severe hypertensive reactions. Get a list from your care provider. Avoid drinking excessive caffeine and chocolate beverages (e.g., coffee, tea, cocoa, or cola). Discuss with physician wearing elastic stockings and elevating legs when sitting to minimize hypotensive effects of drug. Make position changes slowly, especially from recumbent to upright posture, and dangle legs over bed a few minutes before rising to walk. Avoid standing still for prolonged periods. Also avoid hot showers and baths (resulting vasodilatation may potentiate hypotension); lie down immediately if feeling light-headed or faint. Check weight 2 or 3 times per week and report unusual gain. Report jaundice. Hepatotoxicity is believed to be a hypersensitivity reaction unrelated to dosage or duration of therapy. Avoid overexertion while taking this drug. MAO inhibitors may suppress anginal pain that would otherwise serve as a warning sign of myocardial ischemia. Do not breast feed while taking this drug without consulting physician.

Zolpidem

Ambien, Ambien CR Classifications: CENTRAL NERVOUS SYSTEM AGENT; ANXIOLYTIC; SEDATIVE-HYPNOTIC, NON-BENZODIAZEPINE Actions: Nonbenzodiazepine hypnotic. Does not have muscle relaxant or anticonvulsant effects. Therapeutic Effects: Preserves deep sleep (stages 3 and 4) at hypnotic doses. Uses: Short-term treatment of insomnia. Contraindications: Lactation. Cautious Use: Depressed patients, hepatic/renal impairment, older adults, pregnancy (category B), patients with compromised respiratory status. Safety and efficacy in children <18 y are not established. Oral: Give immediately before bedtime; for more rapid sleep onset, do NOT give with or immediately after a meal. Extended-release tablets should be swallowed whole. Ensure that they are not crushed or chewed. Use reduced dosage of 5 mg in older adult or debilitated patients. CNS: Headache on awakening, drowsiness or fatigue, lethargy, drugged feeling, depression, anxiety, irritability, dizziness, double vision. Confusion and falls reported in elderly. Doses >10 mg may be associated with anterograde amnesia or memory impairment. GI: Dyspepsia, nausea, vomiting. Other: Myalgia. Interactions Drug: CNS DEPRESSANTS, alcohol, PHENOTHIAZINES by augmenting CNS depression. Food: Extent and rate of absorption of zolpidem are significantly decreased. Absorption: Readily absorbed from GI tract. 70% reaches systemic circulation. Food decreases rate and extent of absorption. Onset: 7-27 min. Peak: 0.5-2.3h. Duration: 6-8 h. Distribution: Highly protein bound. Lowest concentrations in CNS, highest concentrations in glandular tissue and fat. Crosses placenta, very small amounts (<0.02%) distributed into breast milk. Metabolism: Metabolized in the liver to 3 inactive metabolites. Elimination: 79-96% of dose appears as metabolites in the bile, urine, and feces. Half-Life: 1.7-2.5 h. Nursing Implications Assessment & Drug Effects: Assess respiratory function in patients with compromised respiratory status. Report immediately to physician significantly depressed respiratory rate (less than 12/min). Monitor patients for S&S of depression ; zolpidem may increase level of depression. Monitor older adult or debilitated patients closely for impaired cognitive or motor function and unusual sensitivity to the drug's effects. Patient & Family Education: Avoid taking alcohol or other CNS depressants while on zolpidem. Do not drive or engage in other potentially hazardous activities until response to drug is known. Report vision changes to physician. Note: Onset of drug is more rapid when taken on an empty stomach. Do not breast feed while taking this drug.

Amitriptyline

Amitril, Apo-Amitriptyline , Emitrip, Endep, Enovil, Levate , Meravil, Novotriptyn , SK-Amitriptyline Classifications: CENTRAL NERVOUS SYSTEM AGENT; PSYCHOTHERAPEUTIC; TRICYCLIC ANTIDEPRESSANT Prototype: Imipramine Pregnancy Category: C Availability 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg tablets; 10 mg/mL injection Actions Among the most active of the tricyclic antidepressants (TCAs) in inhibition of serotonin uptake from synaptic gap; also inhibits norepinephrine reuptake to a moderate degree. Restoration of the levels of these neurotransmitters is a proposed mechanism of antidepressant action. Therapeutic Effects Interference with the reuptake of serotonin and norepinephrine results in the antidepressant activity of amitriptyline. Uses Endogenous depression. Unlabeled Uses Prophylaxis for cluster, migraine, and chronic tension headaches; intractable pain, peptic ulcer disease, to increase muscle strength in myotonic dystrophy, to treat pathologic weeping and laughing secondary to forebrain disease, for eating disorders associated with depression (anorexia or bulimia), and as sedative for nondepressed patients. Contraindications Acute recovery period after MI, history of seizure disorders, pregnancy (category C), lactation, children <12 y. Cautious Use Prostatic hypertrophy, history of urinary retention or obstruction; angle-closure glaucoma; diabetes mellitus; hyperthyroidism; patient with cardiovascular, hepatic, or renal dysfunction; patient with suicidal tendency, electroshock therapy; elective surgery; schizophrenia; respiratory disorders; older adults, adolescents. Route & Dosage Antidepressant Adult: PO 75-100 mg/d, may gradually increase to 150-300 mg/d (use lower doses in outpatients) IM 20-30 mg q.i.d. until patient can take PO Adolescent: PO 25-50 mg/d in divided doses, may gradually increase to 100 mg/d (max: 200 mg/d) Geriatric: PO 10-25 mg h.s., may gradually increase to 25-150 mg/d Administration Oral Give with or immediately after food to reduce possibility of GI irritation. Tablet may be crushed if patient is unable to take it whole; administer with food or fluid. Give increased doses preferably in late afternoon or at bedtime due to sedative action that precedes antidepressant effect. Give as single dose at bedtime to promote sleep or for patients with dizziness or when daytime sedation interferes with work productivity. Note that dose is usually tapered over 2 wk at discontinuation to prevent withdrawal symptoms (headache, nausea, malaise, musculoskeletal pain, panic attack, weakness). Intramuscular Reserve IM injections for patients unable or unwilling to take oral drug. Inject deep IM into a large muscle. Store drug at 15°-30° C (59°-86° F) and protect from light unless otherwise directed by manufacturer. Adverse Effects (1%) CNS: Drowsiness, sedation, dizziness, nervousness, restlessness, fatigue, headache, insomnia, abnormal movements (extrapyramidal symptoms), seizures. CV: Orthostatic hypotension, tachycardia, palpitation, ECG changes. Special Senses: Blurred vision, mydriasis. GI: Dry mouth, increased appetite especially for sweets, constipation, weight gain, sour or metallic taste, nausea, vomiting. Urogenital: Urinary retention. Other: (Rare) Bone marrow depression. Interactions Drug: ANTIHYPERTENSIVES may decrease some antihypertensive response; CNS DEPRESSANTS, alcohol, HYPNOTICS, BARBITURATES, SEDATIVES potentiate CNS depression; ANTICOAGULANTS, ORAL, may increase hypoprothrombinemic effect; ethchlorvynol, transient delirium; levodopa, SYMPATHOMIMETICS (e.g., epinephrine, norepinephrine), possibility of sympathetic hyperactivity with hypertension and hyperpyrexia; MAO INHIBITORS, possibility of severe reactions, toxic psychosis, cardiovascular instability; methylphenidate increases plasma TCA levels; THYROID DRUGS may increase possibility of arrhythmias; cimetidine may increase plasma TCA levels. Herbal: Ginkgo may decrease seizure threshold, St. John's wort may cause serotonin syndrome. Pharmacokinetics Absorption: Rapidly absorbed from GI and injection sites. Peak: 2-12 h. Distribution: Crosses placenta. Metabolism: Metabolized in liver to active metabolite. Elimination: Primarily excreted in urine; enters breast milk. Half-Life: 10-50 h. Nursing Implications Assessment & Drug Effects Monitor therapeutic effectiveness. It may take 1-6 wk to reduce attacks when used for migraine prophylaxis. Monitor for S&S of drowsiness and dizziness (initial stages of therapy); institute measures to prevent falling. Also monitor for overdose or suicide ideation in patients who use excessive amounts of alcohol. Lab tests: Baseline and periodic leukocyte and differential counts; renal and hepatic function tests; eye examinations (including glaucoma testing); recommended particularly for older adults, adolescents, and patients receiving high doses/prolonged therapy. Monitor BP and pulse rate in patients with preexisting cardiovascular disease. Assess for orthostatic hypotension especially in older adults. Withhold drug if there is a rise or fall in systolic BP (by 10-20 mm Hg), or a sudden increase or a significant change in pulse rate or rhythm. Notify physician. Monitor I&O, including bowel elimination pattern. Patient & Family Education Monitor weight; drug may increase appetite or a craving for sweets. Understand that tolerance/adaptation to anticholinergic actions (see Appendix F) usually develops with maintenance regimen. Keep physician informed. Relieve dry mouth by taking frequent sips of water and increasing total fluid intake. Make position change slowly and in stages to prevent dizziness. Do not drive or engage in potentially hazardous activities until response to drug is known. Do not use OTC drugs without consulting physician while on TCA therapy; many preparations contain sympathomimetic amines. Note: Amitriptyline may turn urine blue-green. Do not breast feed while taking this drug.

biscodyl

Apo-Bisacodyl , Bisacolax, Bisco-Lax , Dacodyl, Deficol, Dulcolax, Fleet Bisacodyl, Laxit , Theralax Classifications: GASTROINTESTINAL AGENT; STIMULANT LAXATIVE Pregnancy Category: C Availability 5 mg tablets; 10 mg suppository Actions Expands intestinal fluid volume by increasing epithelial permeability. Therapeutic Effects Induces peristaltic contractions by direct stimulation of sensory nerve endings in the colonic wall. Uses Temporary relief of acute constipation and for evacuation of colon before surgery, proctoscopic, sigmoidoscopic, and radiologic examinations. Also used to cleanse colon before delivery and to relieve constipation in patients with spinal cord damage. Contraindications Acute surgical abdomen, nausea, vomiting, abdominal cramps, intestinal obstruction, fecal impaction; use of rectal suppository in presence of anal or rectal fissures, ulcerated hemorrhoids, proctitis. Cautious Use Safety during pregnancy (category C), lactation, or in children is not established. Route & Dosage Laxative Adult: PO 5-15 mg prn (max: 30 mg for special procedures) PR 10 mg prn Child: PO 6 y, 5-10 mg prn PR 2 y, 10 mg; <2 y, 5 mg Administration Oral Give in the evening or before breakfast because of action time required. Give enteric coated tablets whole to avoid gastric irritation; do not cut or crush. Patient should not chew tablets. Preferably give with a full glass (240 mL) of water or other liquid. Do not give within 1 h of antacids or milk. These substances may cause premature dissolution of enteric coating; early release of drug in stomach may result in gastric irritation and loss of cathartic action. Store tablets in tightly closed containers at temperatures not exceeding 30° C (86° F). Rectal Suppository may be inserted at time bowel movement is desired. Storage is same as tablets. Adverse Effects (1%) Systemic effects not reported. Mild cramping, nausea, diarrhea, fluid and electrolyte disturbances (especially potassium and calcium). Interactions Drug: ANTACIDS will cause early dissolution of enteric coated tablets, resulting in abdominal cramping. Pharmacokinetics Absorption: 5-15% absorbed from GI tract. Onset: 6-8 h PO; 15-60 min PR. Metabolism: Metabolized in liver. Elimination: Excreted in urine, bile, and breast milk. Nursing Implications Assessment & Drug Effects Evaluate periodically patient's need for continued use of drug; bisacodyl usually produces 1 or 2 soft formed stools daily. Monitor patients receiving concomitant anticoagulants. Indiscriminate use of laxatives results in decreased absorption of vitamin K. Patient & Family Education Add high-fiber foods slowly to regular diet to avoid gas and diarrhea. Adequate fluid intake includes at least 6-8 glasses/d. Do not breast feed while taking this drug without consulting physician.

Lorazepam

Classifications: CENTRAL NERVOUS SYSTEM AGENT; ANXIOLYTIC; SEDATIVE-HYPNOTIC; BENZODIAZEPINE Antianxiety agent that also causes mild suppression of REM sleep, while increasing total sleep time. Uses: Calms people before surgery Unlabeled Uses: Chemotherapy-induced nausea and vomiting. Contraindications: acute narrow-angle glaucoma Cautious Use: Renal or hepatic impairment; organic brain syndrome; myasthenia gravis; narrow-angle glaucoma; suicidal tendency; GI disorders; older adult and debilitated patients; limited pulmonary reserve. depression, sleep disturbance, restlessness, confusion, hallucinations. CV: Hypertension or hypotension. Special Senses: Blurred vision, diplopia; depressed hearing. GI: Nausea, vomiting, abdominal discomfort, anorexia. Interactions cimetidine increases lorazepam plasma levels, increases toxicity; lorazepam may decrease antiparkinsonism effects of levodopa; may increase phenytoin levels; smoking decreases sedative and antianxiety effects. Herbal: Kava-kava Absorption: Readily absorbed from GI tract. Onset: 1-5 min IV; 15-30 min IM. Peak: 60-90 min IM; 2 h PO. Duration: 12-24 h. Distribution: Crosses placenta; distributed into breast milk. Metabolism: Not metabolized in liver. Elimination: Excreted in urine. Half-Life: 10-20 h. Nursing Implications Assessment & Drug EffectsHave equipment for maintaining patent airway immediately available before starting IV administration. IM or IV lorazepam injection of 2-4 mg is usually followed by a depth of drowsiness or sleepiness that permits patient to respond to simple instructions whether patient appears to be asleep or awake. Supervise ambulation of older adult patients for at least 8 h after lorazepam injection to prevent falling and injury. Lab tests: Assess CBC and liver function tests periodically for patients on long-term therapy. Supervise patient who exhibits depression with anxiety closely; the possibility of suicide exists, particularly when there is apparent improvement in mood. Patient & Family Education: Do not drive or engage in other hazardous activities for a least 24-48 h after receiving IM injection of lorazepam. Do not drink large volumes of coffee. Anxiolytic effects of lorazepam can significantly be altered by caffeine. Do not consume alcoholic beverages for at least 24-48 h after an injection and avoid when taking an oral regimen. Notify physician if daytime psychomotor function is impaired; a change in regimen or drug may be needed. Terminate regimen gradually over a period of several days. Do not stop long-term therapy abruptly; withdrawal may be induced with feelings of panic, tonic-clonic seizures, tremors, abdominal and muscle cramps, sweating, vomiting. Do not self-medicate with OTC drugs; seek physician guidance. Discuss discontinuation of drug with physician if you wish to become pregnant. Do not breast feed while taking this drug

Fludrocortisone

Florinef Acetate Classifications: HORMONE AND SYNTHETIC SUBSTITUTE; ADRENAL CORTICOSTEROID; MINERALOCORTICOID; ANTIINFLAMMATORY AGENT Pregnancy Category: C Availability 0.1 mg tablets Actions Long-acting synthetic steroid with potent mineralocorticoid and moderate glucocorticoid activity. Small doses produce marked sodium retention, increased urinary potassium excretion, and elevated BP. Therapeutic Effects Synthetic corticosteroid replacement product for adrenocortical insufficiency. Uses Partial replacement therapy for adrenocortical insufficiency and for treatment of salt-losing forms of congenital adrenogenital syndrome. Unlabeled Uses To increase systolic and diastolic blood pressure in patients with severe hypotension secondary to diabetes mellitus or to levodopa therapy. Contraindications Hypersensitivity to glucocorticoids, idiopathic thrombocytopenic purpura, psychoses, acute glomerulonephritis, viral or bacterial diseases of skin, infections not controlled by antibiotics, active or latent amebiasis, hypercorticism (Cushing's syndrome), smallpox vaccination or other immunologic procedures. Topical steroids are contraindicated in presence of varicella, vaccinia, on surfaces with compromised circulation, and in children <2 y. Cautious Use Children; diabetes mellitus; chronic, active hepatitis positive for hepatitis B surface antigen; hyperlipidemia; cirrhosis; stromal herpes simplex; glaucoma, tuberculosis of eye; osteoporosis; convulsive disorders; hypothyroidism; diverticulitis; nonspecific ulcerative colitis; fresh intestinal anastomoses; active or latent peptic ulcer; gastritis; esophagitis; thromboembolic disorders; CHF; metastatic carcinoma; hypertension; renal insufficiency; history of allergies; active or arrested tuberculosis; systemic fungal infection; myasthenia gravis. Safety in pregnancy (category C) or lactation is not established. Route & Dosage Adrenocortical Insufficiency Adult: PO 0.1 mg/d, may range from 0.1 mg 3 times/wk to 0.2 mg/d Child: PO 0.05-0.1 mg/d Salt-Losing Adrenogenital Syndrome Adult: PO 0.1-0.2 mg/d Child: PO 0.05-0.1 mg/d Administration Oral Note: Concomitant oral cortisone or hydrocortisone therapy may be advisable to provide substitute therapy approximating normal adrenal activity. Store in airtight containers at 15°-30° C (59°-86° F). Protect from light. Adverse Effects (1%) CNS: Vertigo, headache, nystagmus, increased intracranial pressure with papilledema (usually after discontinuation of medication), mental disturbances, aggravation of preexisting psychiatric conditions, insomnia, ataxia (rare). CV: CHF, hypertension, thromboembolism (rare), tachycardia. Endocrine: Suppressed linear growth in children, decreased glucose tolerance; hyperglycemia, manifestations of latent diabetes mellitus; hypocorticism; amenorrhea and other menstrual difficulties. Special Senses: Posterior subcapsular cataracts (especially in children), glaucoma, exophthalmos, increased intraocular pressure with optic nerve damage, perforation of the globe. Metabolic: Hypocalcemia; sodium and fluid retention; hypokalemia and hypokalemic alkalosis, negative nitrogen balance, decreased serum concentration of vitamins A and C. GI: Nausea, increased appetite, ulcerative esophagitis, pancreatitis, abdominal distension, peptic ulcer with perforation and hemorrhage, melena. Hematologic: Thrombocytopenia. Musculoskeletal: (long-term use) Osteoporosis, compression fractures, muscle wasting and weakness, tendon rupture, aseptic necrosis of femoral and humeral heads. Skin: Skin thinning and atrophy, acne, impaired wound healing; petechiae, ecchymosis, easy bruising; suppression of skin test reaction; hypopigmentation or hyperpigmentation, hirsutism, acneiform eruptions, subcutaneous fat atrophy; allergic dermatitis, urticaria, angioneurotic edema, increased sweating. Body as a Whole: Anaphylactoid reactions (rare), aggravation or masking of infections; malaise, weight gain, obesity. Urogenital: Increased or decreased motility and number of sperm. Interactions Drug: The antidiabetic effects of insulin and SULFONYLUREAS may be diminished; amphotericin B, DIURETICS may increase potassium loss; warfarin may decrease prothrombin time; indomethacin, ibuprofen can potentiate the pressor effect of fludrocortisone; ANABOLIC STEROIDS increase risk of edema and acne; rifampin may increase the hepatic metabolism of fludrocortisone. Pharmacokinetics Absorption: Readily absorbed from GI tract. Peak: 1.7 h. Metabolism: Metabolized in liver. Half-Life: 3.5 h. Nursing Implications Assessment & Drug Effects Monitor weight and I&O ratio to observe onset of fluid accumulation, especially if patient is on unrestricted salt intake and without potassium supplement. Report weight gain of 2 kg (5 lb)/wk. Monitor and record BP daily. If hypertension develops as a consequence of therapy, report to physician. Usually, the dose will be reduced to 0.05 mg/d. Check BP q4-6h and weight at least every other day during periods of dosage adjustment. Lab tests: Periodic serum electrolytes and ABGs during prolonged therapy. Monitor for S&S of hypokalemia and hyperkalemic metabolic alkalosis (see Appendix F). Monitor for signs of overdosage (hypercorticism): psychosis, excess weight gain, edema, congestive heart failure, ravenous appetite, severe insomnia, and increase in BP. Note: Signs of insufficient dosage (hypocorticism) are loss of weight and appetite, nausea, vomiting, diarrhea, muscular weakness, increased fatigue, and hypotension. Patient & Family Education Report signs of hypokalemia (see Appendix F). Be aware of signs of potassium depletion associated with high sodium intake: Muscle weakness, paresthesias, circumoral numbness; fatigue, anorexia, nausea, mental depression, polyuria, delirium, diminished reflexes, arrhythmias, cardiac failure, ileus, ECG changes. Advise patient to eat foods with high potassium content. Signs of edema should be reported immediately. Sodium intake may or may not require regulation, depending on individual needs and clinical situation. Weigh daily under standard conditions and report steady weight gain. Report intercurrent infection, trauma, or unexpected stress of any kind promptly when taking maintenance therapy. Carry medical identification at all times. It needs to indicate medical diagnosis, medication(s), physician's name, address, and telephone number. Do not breast feed while taking this drug without consulting physician

Metformin

Fortamet, Glucophage, Glucophage XR, Glumetza, Riomet Classifications: HORMONES & SYNTHETIC SUBSTITUTES; ANTIDIABETIC AGENT; BIGUANIDES Pregnancy Category: B Availability 500 mg, 850 mg, 1000 mg tablets; 500 mg, 750 mg, 1000 mg sustained-release tablets; 100 mg/mL oral solution Actions Biguanide oral hypoglycemic agent. Unlike sulfonylureas, biguanides do not stimulate the release of insulin from the beta cells of the pancreas. Mechanism of action is thought to be due to both increasing the binding of insulin to its receptor and potentiating insulin action. Therapeutic Effects Improves tissue sensitivity to insulin, increases glucose transport into skeletal muscles and fat, and suppresses gluconeogenesis and hepatic production of glucose, thus lowering blood glucose levels. Uses Treatment of type 2 diabetes mellitus in patients not controlled with diet alone. May be used with an oral sulfonylurea. Contraindications Hypersensitivity to metformin; hepatic or cardiopulmonary insufficiency; alcoholism; concurrent infection; acute MI, cardiogenic shock; diabetic ketoacidosis; hypoxemia, lactic acidosis; radiographic contrast administration; renal disease, renal failure, renal impairment; sepsis; surgery; children <10 y, lactation. Cautious Use Previous hypersensitivity to phenformin or buformin; anemia; coma; dehydration, diarrhea; older adults; ethanol intoxication; fever; gastroparesis, GI obstruction; heart failure; hyperthyroidism, pituitary insufficiency; polycystic ovary syndrome; trauma, emesis; pregnancy (category B). Route & Dosage Type 2 Diabetes Mellitus Adult: PO Start with 500 mg q.d. to t.i.d. or 850 mg q.d. to b.i.d. with meals, may increase by 500-850 mg/d every 1-3 wk (max: 2550 mg/d); or start with 500 mg sustained-release with p.m. meal, may increase by 500 mg/d at p.m. meal qwk (max: 2000 mg/d) Administration Oral Ensure that extend-release tablets are not crushed or chewed. They must be swallowed whole. Use a calibrated oral syringe or container to measure the oral solution for accurate dosing. Give with or shortly after main meals. Withhold metformin 48 h before and 48 h after receiving IV contrast dye. Make dose increment, if needed, at 2- to 3-wk intervals. Store at 15°-30° C (59°-86° F). Adverse Effects (1%) CNS: Headache, dizziness, agitation, fatigue. Metabolic: Lactic acidosis. GI: Nausea, vomiting, abdominal pain, bitter or metallic taste, diarrhea, bloatedness, anorexia; malabsorption of amino acids, vitamin B12, and folic acid possible. Interactions Drug: Captopril, furosemide, nifedipine may increase risk of hypoglycemia. Cimetidine reduces clearance of metformin. Concomitant therapy with AZOLE ANTIFUNGAL AGENTS (fluconazole, ketoconazole, itraconazole) and ORAL HYPOGLYCEMIC DRUGS has been reported in severe hypoglycemia. IODINATED RADIOCONTRAST DYES can cause lactic acidosis and acute kidney failure. Amiloride, cimetidine digoxin, dofetilide, midodrine, morphine, procainamide, quinidine, quinine, ranitidine, triamterene, trimethoprim, or vancomycin may decrease metformin elimination by competing for common renal tubular transport systems. Acarbose may decrease metformin levels. Iodinated contrast dyes may cause lactic acidosis or acute kidney failure. Herbal: Garlic, ginseng may increase hypoglycemic effects. Pharmacokinetics Absorption: 50-60% of dose reaches systemic circulation. Peak: 1-3 h. Distribution: Not bound to plasma proteins. Metabolism: Not metabolized. Elimination: Excreted in urine. Half-Life: 6.2-17.6 h. Nursing Implications Assessment & Drug Effects Lab tests: Obtain baseline and periodic kidney and liver function tests; drug contraindicated in the presence of renal or hepatic insufficiency. Monitor blood glucose and HbA1C, and lipid profile periodically. Monitor known or suspected alcoholics carefully for decreased liver function. Monitor cardiopulmonary status throughout course of therapy; cardiopulmonary insufficiency may predispose to lactic acidosis. Patient & Family Education Be aware that hypoglycemia is not a risk when drug is taken in recommended therapeutic doses unless combined with other drugs which lower blood glucose. Report to physician immediately S&S of infection, which increase the risk of lactic acidosis (e.g., abdominal pains, nausea, and vomiting, anorexia). Do not breast feed while taking this drug without consulting physician

Alendronate

Fosamax, Fosamax D (with 2800 IU Vitamin D3) Classifications: BISPHOSPHONATE; REGULATOR, BONE METABOLISM Prototype: Etidronate Pregnancy Category: C Availability 5 mg, 10 mg, 35 mg, 40 mg, 70 mg tablets; 70 mg/75 mL oral solution Actions Alendronate is a bisphosphonate that inhibits osteoclast-mediated bone resorption. Antiresorption mechanism is not fully understood. It does, however, localize preferentially to resorption sites of active bone turnover and has minimal to no interference with bone mineralization. Therapeutic Effects Alendronate decreases bone resorption thus minimizing loss of bone density. Uses Prevention and treatment of osteoporosis in postmenopausal women, Paget's disease. Treatment of glucocorticoid-induced osteoporosis. Contraindications Hypersensitivity to alendronate or other bisphosphonates; severe renal impairment (Clcr 35 mL/min); hypocalcemia; abnormalities; lactation, pregnancy (category C). Cautious Use Renal impairment, CHF, hyperphosphatemia, liver disease, fever or infection, active upper GI problems. Route & Dosage Treatment of Osteoporosis Adult: PO 10 mg once/d (max: 40 mg/d) or 70 mg q wk Prevention of Osteoporosis, Treatment of Steroid-induced Osteoporosis Adult: PO 5 mg q.d. or 35 mg q wk Treatment of Paget's Disease Adult: PO 40 mg once/d for 6 mo Renal Impairment Clcr <35 mL/min use not recommended Administration Oral Correct hypocalcemia before administering alendronate. Administer in the morning at least 30 min before the first food, beverage, or medication. Do not administer within 2 h of calcium-containing foods, beverages, or medications. At least 30 min should elapse after alendronate dose before taking any other drugs. Oral Solution: Use oral syringe for accurate dosage. Give with at least 60 cc (2 oz) of plain water. Tablet: Give with 8 oz of plain water. Keep patient sitting up or ambulating for 30 min after taking drug. Store according to manufacturer's directions. Adverse Effects (1%) Endocrine: Hypocalcemia, hypophosphatemia. GI: Esophageal irritation and ulceration, nausea, vomiting, abdominal pain, dyspepsia, diarrhea, constipation, flatulence. Other: Arthralgias, myalgias, headache, rash. Interactions Drug: Ranitidine increases alendronate availability. Food: Calcium and food (especially dairy products) reduce alendronate absorption. Pharmacokinetics Absorption: 0.5-1% absorbed from GI tract (absorption significantly decreased by calcium and food). Onset: 3-6 wk. Duration: 12 wk after discontinuation. Distribution: Rapid skeletal uptake. Metabolism: Not metabolized. Elimination: Up to 50% excreted unchanged in urine. Half-Life: Up to 10 h. Nursing Implications Assessment & Drug Effects Lab tests: Monitor albumin-adjusted serum calcium, serum phosphate, serum alkaline phosphatase, fasting and 24 h urinary calcium, and serum electrolytes. Periodically monitor renal and liver functions. Diagnostic test: Bone density scan every 12-18 mo. Discontinue drug if the Clcr <35 mL/min. Patient & Family Education Review directions for taking drug correctly (see ADMINISTRATION). Report fever, especially when accompanied by arthralgia and myalgia. Do not breast feed while taking this drug

Lispro

Humalog Classifications: HORMONE AND SYNTHETIC SUBSTITUTE; ANTIDIABETIC AGENT Prototype: Insulin Injection Pregnancy Category: B Availability 100 units/mL Actions Insulin lispro of recombinant DNA origin is a human insulin that is a rapid-acting, glucose-lowering agent. Therapeutic Effects It lowers blood glucose levels by increasing peripheral glucose uptake, especially by skeletal muscle and fat tissue, and by inhibiting the liver from changing glycogen to glucose. One unit of insulin lispro has the same glucose-lowering ability as human regular insulin, but the effect is more rapid and of shorter duration. Uses Treatment of diabetes mellitus. Contraindications During episodes of hypoglycemia or in patients sensitive to any ingredient in the formulation. Cautious Use In insulin resistant patients, hyperthyroidism or hypothyroidism; lactation, older adults, pregnancy (category B), renal or hepatic impairment. Safety and efficacy in children <3 y are not established. Route & Dosage Diabetes Mellitus (type 1) Adult: SC 5-10 U 0-15 min a.c. (dose adjustments based on blood glucose determinations) Administration Subcutaneous Give 0-15 min before meals. Note: May be given in same syringe with longer-acting insulins but absorption may be delayed. Adverse Effects (1%) (see INSULIN INJECTIONS, REGULAR). Interactions (see INSULIN INJECTION, REGULAR). Pharmacokinetics Absorption: Rapidly absorbed from IM and SC injection sites. Onset: <15 min. Peak: 0.5-1 h. Duration: 3-4 h. Distribution: Throughout extracellular fluids. Metabolism: Metabolized in liver with some metabolism in kidneys. Elimination: <2% excreted in urine. Half-Life: Biological, up to 13 h. Nursing Implications (see INSULIN INJECTION, REGULAR) Assessment & Drug Effects Assess for hypoglycemia from 1 to 3 h after injection. Assess highly insulin-dependent patients for need for increases in intermediate/long-acting insulins. Patient & Family Education Note: Risk of hypoglycemia is greatest 1-3 h after injection. Do not breast feed while taking this drug without consulting physician

Loperamide

Imodium, Imodium AD, Kaopectate III, Maalox Anti-diarrheal, Pepto Diarrhea Control Classifications: GASTROINTESTINAL AGENT; ANTIDIARRHEAL Pregnancy Category: B Availability 2 mg tablets, capsules; 1 mg/mL, 1 mg/5 mL liquid Actions Effective antidiarrheal; synthetic piperidine derivative chemically related to diphenoxylate and to meperidine. Reportedly has longer duration of action. Therapeutic Effects Inhibits GI peristaltic activity by direct action on circular and longitudinal intestinal muscles. Prolongs transit time of intestinal contents, increases consistency of stools, and reduces fluid and electrolyte loss. Uses Acute nonspecific diarrhea, chronic diarrhea associated with inflammatory bowel disease, and to reduce fecal volume from ileostomies. Contraindications Conditions in which constipation should be avoided, severe colitis, acute diarrhea caused by broad-spectrum antibiotics (pseudomembranous colitis) or associated with microorganisms that penetrate intestinal mucosa (e.g., toxigenic Escherichia coli, Salmonella, or Shigella). Safe use during pregnancy (category B), lactation, or in children <2 y is not established. Cautious Use Dehydration; diarrhea caused by invasive bacteria; impaired liver function; prostatic hypertrophy; history of narcotic dependence. Route & Dosage Acute Diarrhea Adult: PO 4 mg followed by 2 mg after each unformed stool (max: 16 mg/d) Child: PO 2-6 y, 1 mg t.i.d.; 6-8 y, 2 mg b.i.d.; 8-12 y, 2 mg t.i.d. Chronic Diarrhea Adult: PO 4 mg followed by 2 mg after each unformed stool until diarrhea is controlled (max: 16 mg/d) Child: PO 0.1 mg/kg after each unformed stool (usually 1 mg) Administration Oral Do not give prn doses to a child with acute diarrhea. Adverse Effects (1%) Body as a Whole: Hypersensitivity (skin rash); fever. CNS: Drowsiness, fatigue, dizziness, CNS depression (overdosage). GI: Abdominal discomfort or pain, abdominal distention, bloating, constipation, nausea, vomiting, anorexia, dry mouth; toxic megacolon (patients with ulcerative colitis). Interactions Drug: No clinically significant interactions established. Pharmacokinetics Absorption: Poorly absorbed from GI tract. Onset: 30-60 min. Peak: 2.5 h solution; 4-5 h capsules. Duration: 4-5 h. Metabolism: Metabolized in liver. Elimination: Primarily excreted in feces, <2% excreted in urine. Half-Life: 11 h. Nursing Implications Assessment & Drug Effects Monitor therapeutic effectiveness. Chronic diarrhea usually responds within 10 d. If improvement does not occur within this time, it is unlikely that symptoms will be controlled by further administration. Discontinue if there is no improvement after 48 h of therapy for acute diarrhea. Monitor fluid and electrolyte balance. Notify physician promptly if the patient with ulcerative colitis develops abdominal distention or other GI symptoms (possible signs of potentially fatal toxic megacolon). Patient & Family Education Notify physician if diarrhea does not stop in a few days or if abdominal pain, distension, or fever develops. Record number and consistency of stools. Do not drive or engage in other potentially hazardous activities until response to drug is known. Do not take alcohol and other CNS depressants concomitantly unless otherwise advised by physician; may enhance drowsiness. Learn measures to relieve dry mouth; rinse mouth frequently with water, suck hard candy. Do not breast feed while taking this drug without consulting physician

Seroquel

QUETIAPINE FUMARATE (Ce-ti-a'peen) Seroquel Classifications: CENTRAL NERVOUS SYSTEM (CNS) AGENT; PSYCHOTHERAPEUTIC AGENT; ANTIPSYCHOTIC, ATYPICAL Prototype: Clozapine Pregnancy Category: C Availability 25 mg, 100 mg, 200 mg tablets Actions Antagonizes multiple neurotransmitter receptors in the brain including serotonin (5-HT1A and 5-HT2) as well as dopamine D1 and D2 receptors. Mechanism of action is unknown, however, antipsychotic properties thought to be related to antagonized responses. Antagonizes histamine H1 receptors resulting in possible somnolence, and adrenergic alpha1 and alpha2 receptors which may lead to orthostatic hypotension. Therapeutic Effects Indicated by a reduction in psychotic behavior. Uses Management of psychotic disorders, management of bipolar disorder. Unlabeled Uses Management of agitation and dementia. Contraindications Hypersensitivity to quetiapine; pregnancy (category C), lactation; alcohol use. Safety and efficacy in children have not been established. Cautious Use Liver function impairment, older adults, cardiovascular disease (history of MI or ischemic heart disease, heart failure, arrhythmias, CVA, hypotension, dehydration, treatment with antihypertensives; history of seizures or suicide; breast cancer; Alzheimer's, Parkinson's disease; concurrent use of centrally acting drugs; patient at risk for aspiration pneumonia; debilitated patients; cerebrovascular disease. Route & Dosage Psychosis, Acute Mania Adult: PO Initiate with 25 mg b.i.d., may increase by 25-50 mg b.i.d. to t.i.d. on the second or third day as tolerated to a target dose of 300-400 mg/d divided b.i.d. to t.i.d., may adjust dose by 25-50 mg b.i.d. q.d. as needed (max: 800 mg/d) Geriatric: PO Initiate with 25 mg b.i.d., titrate more slowly than adult patients, target range 150-200 mg/day in divided doses Agitation, Dementia Geriatric: PO Initiate with 25 mg b.i.d., may increase by 25-50 mg b.i.d. q 2-7 d if needed (max: 200 mg/d) Administration Oral Titrate dose over 4 d usually to a target range of 300-400 mg/d. Make further dose adjustments of 25-50 mg 2 times/d at intervals of at least 2 d. Retitrate to desired dose when patient has been off the drug for >1 wk. Follow recommended lower doses and slower titration for the older adults, the debilitated, and those with hepatic impairment or a predisposition to hypotension. Store at 15°-30° C (59°-86° F). Adverse Effects (1%) Body as a Whole: Asthenia, fever, hypertonia, dysarthria, flu syndrome, weight gain, peripheral edema. CNS: Dizziness, headache, somnolence. CV: Postural hypotension, tachycardia, palpitations. GI: Dry mouth, dyspepsia, abdominal pain, constipation, anorexia. Metabolic: hyperglycemia, diabetes mellitus. Respiratory: Rhinitis, pharyngitis, cough, dyspnea. Skin: Rash, sweating. Hematologic: Leukopenia. Interactions Drug: BARBITURATES, carbamazepine, phenytoin, rifampin, thioridazine may increase clearance of quetiapine. Quetiapine may potentiate the cognitive and motor effects of alcohol, enhance the effects of ANTIHYPERTENSIVE AGENTS, antagonize the effects of levodopa and DOPAMINE AGONISTS. Ketoconazole, itraconazole, fluconazole, erythromycin may decrease clearance of quetiapine. Herbal: St. John's wort may cause serotonin syndrome (headache, dizziness, sweating, agitation). Pharmacokinetics Absorption: Rapidly and completely absorbed from GI tract. Peak: 1.5 h. Distribution: 83% protein bound. Metabolism: Extensively metabolized in the liver by CYP3A4. Elimination: 73% excreted in urine, 20% in feces. Half-Life: 6 h. Nursing Implications Assessment & Drug Effects Monitor diabetics for loss of glycemic control. Reassess need for continued treatment periodically. Withhold the drug and immediately report S&S of tardive dyskinesia or neuroleptic malignant syndrome (see Appendix F). Lab tests: Periodically monitor liver function, lipid profile, thyroid function, blood glucose, CBC with differential. Monitor ECG periodically, especially in those with known cardiovascular disease. Perform baseline cataract exam when therapy is started and at 6 mo intervals thereafter. Monitor patients with a history of seizures for lowering of the seizure threshold. Patient & Family Education Carefully monitor blood glucose levels if diabetic. Exercise caution with potentially dangerous activities requiring alertness, especially during the first week of drug therapy or during dose increments. Make position changes slowly, especially when changing from lying or sitting to standing to avoid dizziness, palpitations, and fainting. Avoid alcohol consumption and activities that may cause overheating and dehydration. Inform physician immediately if you become pregnant. Do not breast feed while taking this drug

Tamsulin

TAMSULOSIN HYDROCHLORIDE (tam'su-lo-sin) Flomax Classifications: AUTONOMIC NERVOUS SYSTEM AGENT; ALPHA-ADRENERGIC ANTAGONIST (SYMPATHOLYTIC AGENT) Prototype: Prazosin HCl Pregnancy Category: B Availability 0.4 mg capsules Actions Antagonist of the alpha1A-adrenergic receptors located in the prostate. Symptoms related to benign prostatic hypertrophy (BPH) are related to bladder outlet obstruction. Therapeutic Effects Blockage of alpha1A-adrenergic receptors can cause smooth muscles in the bladder outlet and the prostate gland to relax, resulting in improvement in urinary blood flow and a reduction in symptoms of BPH. Indicated by improved voiding. Uses Benign prostatic hypertrophy. Contraindications Hypersensitivity to tamsulosin; in conjunction with another alpha1A-adrenergic blocking agent; lactation, pediatric patients. Cautious Use Pregnancy (category B); history of syncope, hypotension. Route & Dosage Benign Prostatic Hypertrophy Adult: PO 0.4 mg q.d. 30 min after a meal, may increase up to 0.8 mg q.d. Administration Oral Give 30 min after the same meal each day. Instruct to swallow capsules whole; not to crush, chew, or open. If dose is interrupted for several days, reinitiate at the lowest dose, 0.4 mg. Store at 20°-25° C (68°-77° F). Adverse Effects (1%) Body as a Whole: Asthenia, back or chest pain. CNS: Headache, dizziness, insomnia. CV: Orthostatic hypotension (especially with first dose). GI: Diarrhea, nausea. Respiratory: Rhinitis, pharyngitis, increased cough, sinusitis. Urogenital: Decreased libido, abnormal ejaculation. Special Senses: Amblyopia. Interactions Drug: Cimetidine may decrease clearance of tamsulosin. Sildenafil, vardenafil, and tadalafil may enhance hypotensive effects. Pharmacokinetics Absorption: Rapidly absorbed from GI tract. >90% bioavailability. Peak: 4-5 h fasting, 6-7 h fed. Distribution: Widely distributed in body tissues, including kidney and prostate. Metabolism: Metabolized in the liver. Elimination: 76% excreted in urine. Half-Life: 14-15 h. Nursing Implications Assessment & Drug Effects Monitor for signs of orthostatic hypotension; take BP lying down, then upon standing. Report a systolic pressure drop of 15 mm Hg or a HR 15 beats upon standing. Monitor patients on warfarin therapy closely. Patient & Family Education Make position changes slowly to minimize orthostatic hypotension. Report dizziness, vertigo, or fainting to physician. Exercise caution with hazardous activities until response to drug is known. Be aware that concurrent use of cimetidine may increase the orthostatic hypotension adverse effect.

acetaminophine

Tylenol Availability 80 mg, 120 mg, 125 mg, 300 mg, 325 mg, 650 mg suppositories; 80 mg, 160 mg, 325 mg, 500 mg tablets; 80 mg/0.8 mL, 80 mg/2.5 mL, 80 mg/5 mL, 120 mg/5 mL, 160 mg/5 mL, 500 mg/5 mL liquid Actions Produces analgesia by unknown mechanism, perhaps by action on peripheral nervous system. Reduces fever by direct action on hypothalamus heat-regulating center with consequent peripheral vasodilation, sweating, and dissipation of heat. Unlike aspirin, acetaminophen has little effect on platelet aggregation, does not affect bleeding time, and generally produces no gastric bleeding. Therapeutic Effects It provides temporary analgesia for mild to moderate pain. In addition, acetaminophen lowers body temperature in individuals with a fever. Uses Fever reduction. Temporary relief of mild to moderate pain. Generally as substitute for aspirin when the latter is not tolerated or is contraindicated. Contraindications Hypersensitivity to acetaminophen or phenacetin; use with alcohol. Cautious Use Children <3 y unless directed by a physician; repeated administration to patients with anemia or hepatic disease; arthritic or rheumatoid conditions affecting children <12 y; alcoholism; malnutrition; thrombocytopenia. Safety during pregnancy (category B) or lactation is not established. Route & Dosage Mild to Moderate Pain, Fever Adult: PO 325-650 mg q4-6h (max: 4 g/d) PR 650 mg q4-6h (max: 4 g/d) Child: PO 10-15 mg/kg q4-6h PR 2-5 y, 120 mg q4-6h (max: 720 mg/d); 6-12 y, 325 mg q4-6h (max: 2.6 g/d) Neonate: PO 10-15 mg/kg q6-8h Administration Oral Administer tablets or caplets whole or crushed and give with fluid of patient's choice. Chewable tablets should be thoroughly chewed and wetted before they are swallowed. Do not coadminister with a high carbohydrate meal; absorption rate may be significantly retarded. Store in light-resistant containers at room temperature, preferably between 15°-30° C (59°-86° F). Rectal Insert suppositories beyond the rectal sphincter. Adverse Effects (1%) Body as a Whole: Negligible with recommended dosage; rash. Acute poisoning: Anorexia, nausea, vomiting, dizziness, lethargy, diaphoresis, chills, epigastric or abdominal pain, diarrhea; onset of hepatotoxicity—elevation of serum transaminases (ALT, AST) and bilirubin; hypoglycemia, hepatic coma, acute renal failure (rare). Chronic ingestion: Neutropenia, pancytopenia, leukopenia, thrombocytopenic purpura, hepatotoxicity in alcoholics, renal damage. Diagnostic Test Interference False increases in urinary 5-HIAA (5-hydroxyindoleacetic acid) by-product of serotonin; false decreases in blood glucose (by glucose oxidase-peroxidase procedure); false increases in urinary glucose (with certain instruments in glucose analyses); and false increases in serum uric acid (with phosphotungstate method). High doses or long-term therapy: hepatic, renal, and hematopoietic function (periodically). Interactions Drug: Cholestyramine may decrease acetaminophen absorption. With chronic coadministration, BARBITURATES, carbamazepine, phenytoin, and rifampin may increase potential for chronic hepatotoxicity. Chronic, excessive ingestion of alcohol will increase risk of hepatotoxicity. Pharmacokinetics Absorption: Rapid and almost complete absorption from GI tract; less complete absorption from rectal suppository. Peak: 0.5-2 h. Duration: 3-4 h. Distribution: Well distributed in all body fluids; crosses placenta. Metabolism: Extensively metabolized in liver. Elimination: 90-100% of drug excreted as metabolites in urine; excreted in breast milk. Half-Life: 1-3 h. Nursing Implications Assessment & Drug Effects Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition or who have ingested alcohol over prolonged periods; poisoning, usually from accidental ingestion or suicide attempts; potential abuse from psychological dependence (withdrawal has been associated with restless and excited responses). Patient & Family Education Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects. Do not self-medicate adults for pain more than 10 d (5 d in children) without consulting a physician. Do not use this medication without medical direction for: fever persisting longer than 3 d, fever over 39.5° C (103° F), or recurrent fever. Do not give children more than 5 doses in 24 h unless prescribed by physician. Do not breast feed while taking this drug without consulting physician

Ondansetron

Zofran, Zofran ODT Classifications: GASTROINTESTINAL AGENT; ANTIEMETIC; 5-HT3 ANTAGONIST Pregnancy Category: B Availability 4 mg, 8 mg, 24 mg tablets; 4 mg, 8 mg orally disintegrating tablets; 4 mg/5 mL oral solution; 2 mg/mL, 32 mg/5 mL injection Actions Selective serotonin (5-HT3) receptor antagonist. Serotonin receptors are located centrally in the chemoreceptor trigger zone (CTZ) and peripherally on the vagal nerve terminals. Serotonin is released from the wall of the small intestine and stimulates the vagal efferents through the serotonin receptors and initiates the vomiting reflex. Therapeutic Effects Prevents nausea and vomiting associated with cancer chemotherapy and anesthesia. Uses Prevention of nausea and vomiting associated with initial and repeated courses of cancer chemotherapy, including high-dose cisplatin; postoperative nausea and vomiting. Unlabeled Uses Treatment of hyperemesis gravidarum Contraindications Hypersensitivity to ondansetron. Cautious Use Pregnancy (category B), lactation. Route & Dosage Nausea and Vomiting Adult: PO 8 mg 30 min before chemotherapy, then q8h times 2 more doses Adult/Child: IV 6 mo-18 y, 0.15 mg/kg or 32 mg infused over 15 min beginning 30 min before start of chemotherapy, followed by 0.15 mg/kg 4 and 8 h after first dose of ondansetron, may also give 8 mg bolus, then 1 mg/h by continuous infusion (max: 32 mg/d), or 32 mg as single dose Child: PO >4 y, 4 mg 30 min before chemotherapy, then q8h times 2 more doses Nausea & Vomiting with Highly Emetogenic Chemotherapy Adult: PO Single 24-mg dose 30 min before administration of single-day highly emetogenic chemotherapy Postoperative Nausea and Vomiting Adult: PO 8-16 mg 1 h preoperatively IM 4 mg injected immediately prior to anesthesia induction or once postoperatively if patient experiences nausea/vomiting shortly after surgery IV 4 mg by slow IV push, may repeat q8h as needed Child: IV 1 mo-12 y, 0.1 mg/kg Hyperemesis Gravidarum Adult: PO/IV 4-8 mg 2-3 times per day Hepatic Impairment Maximum dose 8 mg/d PO/IV in patients with severely impaired liver function according to Child-Pugh criteria Administration Oral Give tablets 30 min prior to chemotherapy and 1-2 h prior to radiation therapy. Do NOT push orally disintegrating tablet through blister foil. Peel foil back and remove tablet. Tablets will disintegrate with/without liquid. Intravenous PREPARE: Direct: May be given undiluted. IV Infusion: Dilute a single does in 50 mL of D5W or NS. May be further diluted in selected IV solution. ADMINISTER: Direct: Give over at least 30 sec, 2-5 min preferred. IV Infusion: Give over 15 min. When three separate doses are administered, infuse each over 15 min. INCOMPATIBILITIES Solution/additive: Meropenem. Y-site: Acyclovir, allopurinol, aminophylline, amphotericin B, ampicillin, ampicillin/sulbactam, amsacrine, cefepime, cefoperazone, fluorouracil, furosemide, ganciclovir, lorazepam, meropenem, methylprednisolone, piperacillin, sargramostim, sodium bicarbonate, TPN. Adverse Effects (1%) CNS: Dizziness and light-headedness, headache, sedation. GI: Diarrhea, constipation, dry mouth, transient increases in liver aminotransferases and bilirubin. Body as a Whole: Hypersensitivity reactions. Interactions Drug: Rifampin may decrease ondansetron levels. Pharmacokinetics Peak: 1-1.5 h. Metabolism: Metabolized in liver. Elimination: 44-60% excreted in urine within 24 h; approximately 25% excreted in feces. Half-Life: 3 h. Nursing Implications Assessment & Drug Effects Monitor fluid and electrolyte status. Diarrhea, which may cause fluid and electrolyte imbalance, is a potential adverse effect of the drug. Monitor cardiovascular status, especially in patients with a history of coronary artery disease. Rare cases of tachycardia and angina have been reported. Patient & Family Education Be aware that headache requiring an analgesic for relief is a common adverse effect.

Olanzapine

Zyprexa, Zyprexa Zydis, Zyprexa IntraMuscular Classifications: CENTRAL NERVOUS SYSTEM (CNS) AGENT; PSYCHOTHERAPEUTIC AGENT; ANTIPSYCHOTIC AGENT; ATYPICAL; SELECTIVE SEROTONIN REUPTAKE INHIBITOR; DOPAMINE-REUPTAKE INHIBITOR Prototype: Clozapine Pregnancy Category: C Availability 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg tablets; 10 mg, 15 mg, 20 mg orally-disintegrating tablets; 10 mg powder for injection Actions Antipsychotic activity is thought to be due to antagonism for both serotonin 5HT2A/2C and dopamine D1-4 receptors. May inhibit the CNS presynaptic neuronal reuptake of serotonin and dopamine. Antagonism of alfa-adrenergic receptors results in the adverse effect of orthostatic hypotension. Therapeutic Effects Produces antipsychotic and anticholinergic activity. Uses Management of psychotic disorders, treatment of bipolar disorder, acute agitation (IM). Unlabeled Uses Alzheimer's dementia. Contraindications Hypersensitivity to olanzapine; abrupt discontinuation, coma, severe CNS depression, subcutaneous or intramuscular injection of olanzapine; tardive dyskinesia; infants, pregnancy (category C), lactation. Cautious Use Known cardiovascular disease, neurological disease, stroke, cerebrovascular disease, Parkinson disease, dementia; history of seizures, conditions that predispose to hypotension (i.e., dehydration, hypovolemia); history of syncope; history of breast cancer; Japanese; diabetes mellitus; prostatic hypertrophy; closed-angle glaucoma; paralytic ileus; urinary retention; hepatic or renal impairment, concurrent use of hepatotoxic drugs, jaundice; predisposition to aspiration pneumonia; may increase risk of stroke in elderly patients with dementia; history of or high risk for suicide. Safety and effectiveness in children <18 y are not established. Route & Dosage Psychotic Disorders Adult: PO Start with 5-10 mg once/d, may increase by 2.5-5 mg q wk until desired response (usual range 10-15 mg/d, max: 20 mg/d) Geriatric: PO Start with 5 mg once/d Bipolar Mania Adult: PO Start with 10-15 mg once/d, may increase by 5 mg q24h if needed Acute Agitation Adult: IM 10 mg, do not repeat more frequently than q2h (max: 30 mg/24h) Geriatric: IM 2.5-5 mg once Administration Oral Do not push orally disintegrating tablet through blister foil. Peel foil back and remove tablet. Tablet will disintegrate with/without liquid. Adverse Effects (1%) Body as a Whole: Weight gain, fever, back and chest pain, peripheral and lower extremity edema, joint pain, twitching, premenstrual syndrome. CNS: Somnolence, dizziness, headache, agitation, insomnia, nervousness, hostility, anxiety, personality disorder, akathisia, hypertonia, tremor amnesia, euphoria, stuttering, extrapyramidal symptoms (dystonic events, parkinsonism, akathisia), tardive dyskinesia. CV: Postural hypotension, hypotension, tachycardia. Special Senses: Amblyopia, blepharitis. GI: Abdominal pain, constipation, dry mouth, increased appetite, increased salivation, nausea, vomiting, elevated liver function tests. Metabolic: Hyperglycemia, diabetes mellitus. Urogenital: Premenstrual syndrome, hematuria, urinary incontinence, metrorrhagia. Respiratory: Rhinitis, cough, pharyngitis, dyspnea. Skin: Rash. Interactions Drug: May enhance hypotensive effects of ANTIHYPERTENSIVES. May enhance effects of other CNS ACTIVE DRUGS, alcohol. Carbamazepine, omeprazole, rifampin may increase metabolism and clearance of olanzapine. Fluvoxamine may inhibit metabolism and clearance of olanzapine. Herbal: St. John's wort may cause serotonin syndrome (headache, dizziness, sweating, agitation). Pharmacokinetics Absorption: Rapidly absorbed from GI tract, 60% reaches systemic circulation. Onset: 15 min IM. Peak: 6 h. Distribution: 93% protein bound, secreted into breast milk of animals (human secretion unknown). Metabolism: Metabolized in liver, primarily by cytochrome P450 1A2 (CYP1A2). Elimination: Approximately 57% excreted in urine, 30% in feces. Half-Life: 21-54 h. Nursing Implications Assessment & Drug Effects Monitor diabetics for loss of glycemic control. Withhold drug and immediately report S&S of neuroleptic malignant syndrome (see Appendix F); assess for and report S&S of tardive dyskinesia (see Appendix F). Lab tests: Periodically monitor ALT, especially in those with hepatic dysfunction or being treated with other potentially hepatotoxic drugs. Periodic blood glucose monitoring. Monitor BP and HR periodically. Monitor temperature, especially under conditions such as strenuous exercise, extreme heat, or treatment with other anticholinergic drugs. Monitor for seizures, especially in older adults and cognitively impaired persons. Patient & Family Education Carefully monitor blood glucose levels if diabetic. Do not drive or engage in potentially hazardous activities until response to drug is known; drug increases risk of orthostatic hypotension and cognitive impairment. Learn common adverse effects and possible drug interactions. Avoid alcohol and do not take additional medications without informing physician. Do not become overheated; avoid conditions leading to dehydration. Do not breast feed while taking this drug.

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